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Professor Ian Campbell Roddie

Ian Roddie was my wife Mary's much loved father who died in 2011. He was Professor of Physiology at Queen's University in Belfast.

He was an inspiring teacher and one of the best speakers to whom I have had the pleasure to listen, being able to keep his audience attentive throughout because of his obvious knowledge and love of the subject about which he spoke combined with his wonderful Irish humour. He was also, fortunately for us, a great believer in the importance of historical documents and maintained a detailed record of his family and academic life including transcripts of all of his major speeches and publications.

In February 2014 I added this new page to the website on which I will, from time to time, be adding snippets from his documented memoirs. I have started with two articles that he wrote on Medical Education, about which he had firm views. The first he wrote in 1990 and is entitled 'The Pre-emptive Cringe' in which he gives his forthright opinion about what he thought of those academics who sold out their universities to government funding agencies in order to curry favour.

The second is a short article called 'The Quality of Teaching' that summarises a presenatation that he gave in London at a Royal College of Physicians symposium on Medical Education in 1987 in which he stresses the importance of inspirational teachers.


The Writings of Ian Roddie


'The Bride and her father'

A Wedding Speech - Mary and James 22nd July 1989

(To see a comment regarding this article go to the 22nd July 2014 blog)

Speech given at James and Mary's Wedding Reception at the Royal Society of Medicine

As the father of the bride, I have two functions today.  One is to give the bride away – which I have done – and the other – which I am about to do – is to make a speech to propose the health of the bride and groom and, incidentally, welcome you as guests and thank you for helping to make today the memorable one we would wish for Mary and James.  We want this to be a day that Mary and James will remember with pleasure for the rest of their lives.  And hopefully you too in the future will be able to look back with great pleasure to this celebration which marks the beginning of their married life together.

For my part, I have been looking forward to today.  The "father of the bride" is a role I've always wanted to play ever since I saw Spencer Tracy and Myrna Loy in the film of the same name many years ago.  He was wonderful as the father, a perfect role model.  If any of you saw it, you may remember that the part of the daughter was played by the young Elizabeth Taylor.  I can remember thinking how beautiful she was, but, if you will allow me the prejudice of a proud father for his first born girl, she was not nearly as beautiful as the lovely bride of today.

Now it is my turn to play the part and so far it has lived up to my expectation.  It has been great fun. After the weeks of preparations and rehearsals, the big day comes. It starts at a furious pace but gradually slackens as people slip away as advance parties to this and that.  Finally you are left alone in an empty house with your daughter and it is time to go.  Then, trying not to fuss but wondering what you have forgotten to do, in a state somewhere between giggles and tears, but trying to look serious, both of you bundle into the car, feeling conspicuous and, speaking for myself, slightly foolish.  You try to smile nonchalantly at the photographer but the main preoccupation is not to crush the bride's dress.  That bit is not easy.  But then there is the drive through the city to the church, where, finally you stand at the back with a dry mouth and racing pulse waiting to walk down the aisle, arm in arm with the young woman who has changed from a small girl into a radiant bride in an incredibly short space of time – and you feel the special rapport that binds a father to his daughter on her wedding day.  There is no doubt, the father of the bride is a very privileged man.

Of course, the pride and pleasure of giving away a daughter such as Mary is bound to be tinged with a certain sadness.  It would be unnatural otherwise.  But it is a consolation to know that in the future, she will have a husband such as James to care for her and, speaking personally, I am very happy to have James as a son-in-law.  I think it is obvious that Mary shares this view.  I hold James in high regard and this is not something that should not be taken for granted since, as you know, ‘sons-in-law’ and ‘high regard’ do not necessarily go hand in hand.  Sons-in-law are not everyone's cup of tea and like mothers-in-law, their good qualities cannot always be taken as self-evident.

Some of you may have heard of Richard Feynman.  He was the physicist awarded a Nobel Prize for his part in discovering the neutrino, an atomic particle.  Except for its spin (and Feynman got the prize for his analysis of the spin), the neutrino is not very exciting; it has no electric charge, no mass and doesn't seem to react with any of the other atomic particles.  It really doesn't seem capable of doing anything.  Feynman said he had difficulty in interesting people in an object that could be shown to exist – but in every other sense seems absolutely useless – he said that the only thing it really reminded him of – was his son in law.

Now James is not like that.  He is really quite useful.  Not only is he good at his work but, to my direct knowledge, he can do really useful things like put up shelves, erect built-in cupboards, paint walls, put up shower curtains, cut armoured glass to make cat doors in burglar proof windows and broadly speaking carry out most of the tasks that any wife could reasonably expect of a husband.  He is, as some of you may know, especially gifted at plumbing; he even installed his own central heating!  I have made use of these skills myself.  Some of you who stayed in my old house, Seapark, at Holywood may remember that a major tribulation for guests was learning to work the flush system in the upstairs bathroom lavatory.  Over the years its perversity made many an otherwise strong and self-confident person feel an inadequacy, insecurity and occasionally an embarrassment more appropriate for childhood.  If you were one of these guests, you will be pleased to know that James, on his first visit to Seapark, was able to diagnose and prescribe for the lesion which had caused so much anguish to so many for so long.  It is a pity he did not cure it as well!  However, should the medical profession ever collapse, I have no doubt that James could still support my daughter by exploiting his handyman skills – James does not remind me of a neutrino.  He does not behave like one – and frankly in my opinion, he doesn't even look like one!

And he has other good qualities.  He is tolerant of cats.  That might sound trivial but it is an important quality where Mary's happiness is concerned.  With Mary it is very much a matter of love me, love my dog or, to be more exact in her case, love my cats, Big Cat and Little Cat in particular.  Though I think James's tolerance of cats is acquired rather than inborn, nevertheless I have been very impressed with his good humoured patience with cat talk, cat ornaments, cat food, cat doors, cat portraiture and even cat radiology.  When Big Cat had his accident, the considerable veterinary and radiological skills of the entire Jackson family were instantly mobilized to avert tragedy and Big Cat's continued good health, indeed his very existence, owes much to their good offices.

Some of you may know of Mary's interest in computer graphics.  Recently she let me have one of her first compositions.  Here it is, a one page computer drawing collage of her three dearest things, Little Cat, Big Cat and James in that order.  James has been scaled down in size of course to fit him in – though some might think a bit excessively in that he ends up considerably smaller than either of the cats!  And a somewhat paranoid person might also query why the legends for Big Cat and Little Cat are in upper case characters while those for James are lower case.  But James is not upset by this, he accepts his place in the grand order of things with what can only be described as exemplary good grace.  Of course, he comes from a tolerant family, a tolerance which Mary tests occasionally as, for example, when she accidentally dropped an iron gate on Dr Jackson's head while they were dipping sheep together at the Jackson's Norfolk farm.  It is said that he took it all with great equanimity – though, to be absolutely fair, I should also report that he is looking for another assistant.

It seems that James is also quite tolerant of Mary's career ambitions.  Many of you will know that James and Mary were appointed to the same posts in the same hospital on the same day and in that competitive environment are, in a sense, competing with one another for a place in the radiological sun.  Both have been very successful and James has been very supportive.  In fact, Mary once told me that she wished that she could be as pleased to hear about James successes as he seemed to be to hear about hers.

Of course some people would not be surprised by this; they would claim that women are naturally more jealous than men, so what else would you expect!  Not me of course – I have much more sense.  But if there are any liberated women here today, they will be interested to know that the idea of woman's natural jealousy is accepted without question in Japan and, in fact, has been institutionalized into their Shinto wedding ceremony.  For this ceremony, brides wear a simple white kimono called a UCHIKAKE and it has a white hood called a WATA-BOSHI.  The hood has a double significance – the white symbolizes purity and the head cover is designed to hide the symbolic horns of woman's natural jealousy.  Needless to say, I was amazed by such primitive and chauvinistic thinking and asked what the men wore, what was a male equivalent of the wata-boshi?  However, they explained to me that men do not need to wear a wata-boshi since everyone in Japan knows that men do not suffer from jealousy.  A remarkable people the Japanese, one has to admit that they are often right, though perhaps not in this case.

There is no doubt, some of the ideas and customs of the East are quite fascinating and stimulating – especially perhaps for the liberated woman – but also, I must admit, for unliberated men like myself.  What with working there for the last few years and Mary's wedding coming up, I have become more and more interested in how they think about marriage and courtship.  While there are superficial differences, it is interesting that at the fundamental human level, it is the similarities rather than the differences that impress.

For example, in India, men in theory are not the hunters but the hunted, they wait to be chosen.  The hunters actually, are the parents of the bride.  But the bride is not entirely passive.  Though she has an arranged marriage, she is allowed to give her parents a profile of the man she would like to marry; it is a restricted form of natural selection.  That struck a chord with me since I remembered that Mary had once given me a profile of the man she would like to marry and that was long before she had met James.  The person she wanted should be ambitious, intelligent, handsome, trustworthy, faithful and supportive of her career, someone she could look up to and someone for whom family life and children would be very important.  Quite a check list really – No one could ever accuse Mary of not being particular!

Now if this had been India, I would have been part of the search committee seeking out such a paragon.  Since it is not, I am afraid I played little part in James's election.  However, as it happens, there was a surrogate search committee and I am pleased to say that some of the people who served on it are here today.  They are, of course, the members of the appointment panel at the Hammersmith who set in motion the whole process that has culminated here today.  As cupids, they did well – But isn't it a relief that they picked the right people!  Otherwise we would have had no excuse for today's celebrations.  All credit then to Professor Allison, Prof Lavender and their colleagues for their part in making today happen.

In Hong Kong where I now work, the young ladies take a more active and perhaps more materialistic approach than would be the case in India.  When thinking of marriage (and many think of little else), what they look for in a husband are the 6 M qualities – the mates that they marry should be Male, Macho and have Money, a Mansion, a Mercedes motor car and a Mobile phone and for all these qualities the more  the merrier.  I have scored James on this.  I am afraid he only gets 3 out of 6 – well perhaps 3.5 out of six if you mark his Volkswagen Golf a little generously.  On the positive side, however, 50% is not a disastrous score even by Hong Kong standards and might be enough to get him onto the short list – perhaps even called to interview.  And I have no doubt that if James got to interview, his good qualities would easily win him the day.

In Singapore it's different again; there they take a more eugenic line on marriage.  The government, you see, is worried that graduate women are not having enough children.  Worse still, it believes that many men seek out stupid women as wives because, like most men, they do not want their intellectual superiority to be in question.  Of course the women may only be pretending to be stupid; in Singapore it is said that when a man feels that he is intellectually superior to his wife, he probably has a very smart wife.  Anyway, in an attempt to get smart people to marry one another and have lots of babies, the government of Singapore has set up what are basically marriage bureaus for graduates which they euphemistically call SDUs or Social Development Units.  In these units graduates of both sexes are encouraged to meet, mingle, marry and then hopefully have the sort of baby that Lee Kwan Yew feels is needed to maintain Singapore as a centre of excellence into the next century – I have a feeling that he would approve of this marriage!

From what I hear, the philosophies of Singapore and the department of Radiology at the Hammersmith have similarities.  Both set themselves high standards, tend to be elitist, practice a sort of guided or paternalistic democracy and have high aspirations for the future.  I have asked myself – how might Mary and James help further this ambition?  As you know they are both good radiologists.  I don't know if there is a special gene for this – or, if so, whether it is a dominant or recessive one – I suspect it is neither; as a trait, radiology is more likely to be multifactorial.  But who knows?  Perhaps one day they will have lots of little radiologists who will grow up into big radiologists and help to maintain the Hammersmith as a centre of radiological excellence into the next century.  I suspect that that would be all right and that Professor Allison might approve.  However, speaking for myself, even if they never become radiologists – or even physiologists for that matter – I will still look forward with great pleasure and anticipation to meeting them when they arrive and then getting to know them.

It is time I spoke of Mary.  You would not expect objectivity from a father about his daughter or her wedding day nor, indeed, will you get it.  Mary has been everything a father could want in a daughter.  That applies ever since she was a happy little embryo communicating with cheerful gusto through her mother’s abdominal wall.  As a new-born baby she was absolutely breath-taking and her mother and I would sit for hours on end gazing at her in her cot wondering how people like us could have produced something quite so beautiful and exquisite.  We named her after both her grandmothers, both in their very different ways quite remarkable women and, happily, she has inherited some of the best qualities of each.

When young she travelled extensively, both as an embryo and as a small baby.  At one time she was the youngest passenger on the liner, the Queen Mary (very appropriate too we thought at the time) and, before she was one, she had probably slept in enough bath tubs in enough motels right across North America to have merited an entry in the Guinness Book of Records.  Responsibility came early.  By the age of 5 she had 3 younger siblings and occasionally had to be scolded for not setting them the mature example we unreasonably expected of a child of five.

Little episodes still stick in the mind.  I will not forget her hurt fury when once, before going on holiday, I took her with her sisters to a barber shop in Holywood where they were given boy-style hair-cuts – it seemed so sensible – there would be so much less hair to dry after bathing.  But, despite their young age, they have never forgotten that insult to their crowning glory, nor I believe have they yet forgiven me.  Happily they have all turned out into very feminine beautiful young women so I console myself that I did not do them, or their self-image, lasting harm.  I also remember Mary's utter joy mixed with absolute disillusionment at my lack of medical judgement, when her hamster called Hannah, or was it Hazel – or Horace – I forget which, twitched a whisker and opened an eye while lying in state in the improvised coffin in which I was about to bury him or her in the mistaken belief that he or she was dead.  I also remember her grit and determination in getting on her bike in the early mornings to ride the seven hilly miles to the Ulster Hospital Dundonald for her early shift as an assistant nurse in a geriatric ward.  And I will not forget her strength of will in arguing with her very formidable headmaster that she should leave school to concentrate exclusively on the A levels grades she needed to read medicine and felt convinced she would not get if she stayed on at his establishment.

Throughout everything she has been a most organized girl, with a view to the future and a planning capacity to match.  Like a rock, she helped to give a much needed order and stability to our frequently disturbed and chaotic home.

Much of this wedding she has organized herself while preparing for the final examinations in radiology (in which, by the way, I'm glad to say that both she and James were successful), going to Athens to give papers and continuing her ordinary busy hospital life together with looking after her cats, her flat, my house in London, making James' house habitable and many other things.  So Mary I would like you to know that in your father’s eyes, as in so many others both past and present, you are and have been a wonderful daughter in both good times and in bad, truly a daughter for all seasons.  And if you can provide James with the same intelligent love, support and loyalty that you have given to your family, James will indeed be a fortunate man.  May all your hopes and dreams come true.

Well I should stop there.  You may have heard of the little girl who when asked if she could spell "banana" said she could – but she wasn't quite sure where to stop.  Or in the same vein, of the long-winded Scottish cleric – when his verger was asked by a latecomer to the morning service had the minister finished his sermon, he replied, "Yes, he finished it some time ago but he hasn't actually stopped yet".  I fear that that may be fair comment on my position.

But before finishing there are some people I really must thank.  Firstly, I would like to thank the staff of the RSM for looking after us so well this afternoon and for their patience in tolerating us for so long.  I would also like to thank Mr Evans and the staff at St Paul's for the contribution they made to make this a truly memorable day.  The chapel and the crypt were beautiful as was the conduct of the service. A very special word of thanks is required for my cousin Robin Roddie, who has modified his summer plans so that he could be with us today to assist with the wedding ceremony and make it a very special family occasion.  I should also say how pleased I am that his wife Roberta was able to be with him also.  I would like to thank Dr & Mrs Jackson for the contributions they have made to today's success.  The greatest of these of course was their eldest son, James – I'm sure you would agree – it just would not have been the same without him!  But besides James, we owe the splendid wedding cake to Mrs Jackson's artistic and culinary skills.  Thank you both very much.  Most of all, my wife and I would like to thank all of you for coming as guests to make this day such a happy and successful one.  I know that many of you have had to make a great effort and come long distances to be here.  This applies to many but especially to some of my dear relatives who may have found the travel at this time of the year especially arduous.  They have been a great source of support and comfort to all the members of my immediate family, including Mary, throughout our lives and today, predictably, has been no exception.  We have valued this support and concern over the years more highly than we can possibly express and we will never forget it.  And lastly, I would also like to thank those people who I know would have loved to come but because of age, health or other pressing commitments could not actually be with us.  I would like to thank them for their kind thoughts and good wishes.

And now, you will be relieved to know, not only have I finished but I am about to stop as well.  So let us proceed with the toasts.  I would ask you all to raise your glasses to toast the health and happiness of the bride and groom.



'University students'

A Critique of Fashion in Medical Education

Some thoughts on the report of the Panel on the General Professional Education of the Physician and College Preparation for Medicine

(To see a comment regarding this article go to the 22nd June 2014 blog)

Reprinted from NEW YORK STATE JOURNAL OF MEDICINE, Vol. 86, August 1986: From a lecture given June 14, 1985 at a symposium on “Medical Education in the 21st Century” held at the Bowman Gray School of Medicine. Wake Forest University, Winston-Salem, NC.

though folly’s child
and the guide of fools,
rules even the wisest
and in learning, rules.
George Crabbe, 1754-1832

These lines by Crabbe, the East Anglian poet/surgeon/cleric, written about 200 years ago, express well how fashion can dominate the thinking of even the wisest people and is paramount in educational matters. However, though it is easy to complain about the influence of fashion on education, it’s not so easy to do much about it in practice. In something as complicated as medical education, where it is virtually impossible to prove or disprove a hypothesis with certainty, arguments may do little but illustrate the prejudices of those taking part. This may explain the reticence of the wiser among us in not adding to the noise levels in such debates. Their most eloquent comment may be their silence. Perhaps I will grow wiser one day and keep my mouth shut but I have been so disturbed and angered by the cynicism and the damage to academic standards and morale that often follow the introduction of half-baked educational systems into our medical schools that I am grateful for being allowed to air some of my prejudices on the subject. I know virtually nothing about educational theory; my thoughts and feelings on medical education come from some 40 years of teaching and being taught in universities in different parts of the world.

In my lifetime I have seen so many fashionable theories wither in the light of experience that my faith in theories as a guide to truth is slim. Experience has shown that most simple theories, whether they deal with economics, politics, education, or whatever, no matter how logical, fashionable, or attractive they sound at the time, usually do not work well when tried out in real life situations. If this means that we must muddle through with pragmatism and what I like to think is common sense, so be it.

Nothing beats experience for evaluating theories. My father was a clergyman. When he was a young minister he gave a talk that was popular at meetings of young mothers in his parishes. He called it, “The ten cardinal points for bringing up children.” Then he married and had four normal, healthy children, of which I was the third. The ten points soon fell to seven. When it reached three he abandoned the talk. A generation later, the enlightened theories of Dr Spock provided my wife and me with the up-to-date, modern model we hoped would result in problem-free, happy, and fulfilled children. Now that our children have grown up, I wonder, could this be where we went wrong?

When I was young I was an expert on America. I had watched so many American movies that I felt entitled to pontificate on all things American. In 1960, however, the Harkness Foundation gave me a fellowship to work and travel here. A condition of the fellowship was that, in addition to spending a year or so working in a university, I should spend several months not visiting universities, but exploring the country, meeting people and just going wherever I wished. They provided me with a rented car to do it. Though this seemed self-indulgent and rather offended my work ethic at the time, the four months spent with my wife and baby daughter touring America and meeting Americans were amongst the most memorable and instructive in my life. Never again could I generalize about the characteristics of this great conglomerate of nations, attitudes, life-styles, terrains, and climates. America (and medical education for that matter) does not lend itself to such over-simplifications. The only common thread throughout our journey was the great kindness and hospitality shown to us in all parts of the country.

As an eager young academic, I knew exactly what was wrong with medical education. When I was made chairman of my department I had an early opportunity to correct matters by trying out the newer educational theories on our students that for some strange reason my predecessors had seemingly ignored. To my great disappointment, their implementation often made little difference to the students’ happiness or level of achievement, but caused them some anxiety and the department considerable extra work and expense. We tried to salvage the best of each new system and graft it onto the old, but mostly it might have been better to concentrate on improving the old system and avoid the disruption that the change in curriculum caused.

It is against this background of lost innocence that I react so negatively to people who complain stridently that traditional medical education is virtually useless, if not harmful, and that if we would only implement the latest new educational theories, it would make it all better. Especially so when it is said in a pompous way with near evangelical zeal on equivocal evidence. Life just isn’t as simple as that. I go along with Malcolm Frazer, the ex-prime minister of Australia, who said, “Life wasn’t meant to be easy.” I hope I will not be thought too complacent for my opinion that the traditional medical curriculum provides one of the most interesting and absorbing courses available in a university. It is not perfect nor would I expect it ever to be so. Nevertheless, I would treat it with respect and not tamper with it lightly since its evolution has drawn on some of the best minds and highest ideals in human history.

Some of my early and arrogant efforts to improve our own curriculum were as counter-productive and vandalistic as my effort to improve the appearance of a Victorian brass bed by sawing off its elegant but extravagant superstructure. I am not sorry that the inertia in most medical schools protects them from the worst excesses of educational vandals; that degree of protection is needed today more than ever.

Of course I would not want to prevent change and could not prevent it even if I did. New people and new ideas will always keep our curriculum on the move and it has to adapt to changing times and conditions. That is why it is as good as it is. But I would worry if the rate of change were so great that there was not the time to evaluate the merit or otherwise of the changes introduced or if it resulted in irretrievable loss of some of our traditional strengths.

Perhaps then you will bear with me if I discuss some of the recommendations in the GPEP Report, also known as Physicians for the Twenty-First Century, since I feel they incorporate some of the fashion of our time. It would be surprising of course if they did not. Though spelt out at some length in the report, they can be summarized briefly. In general they deal with matters of emphasis rather than matters of absolutes. On student selection, it is recommended that medical students should have a broader educational and social background and be selected on personal characteristics rather than just academic performance. On curriculum content, it is recommended that emphasis should be put on principles rather than facts; attitudes and skills as much as knowledge; the medicine of the future as much as the medicine of the past; and the medicine of the community as much as the medicine of the specialist hospital. On curriculum organization, the report recommends that medical education should be faculty rather than department-based; integrated rather than subject-based; and active rather than passive. With regard to student assessment, it recommends that evaluation should be subjective rather than objective and continuous rather than periodic. It also recommends drawing up clear educational objectives, fostering literacy, and, perhaps predictably, spending more public money on medical education.

Now these sound quite logical and, when younger, I might have accepted them more easily. However, now that I am older I have reservations about them as panaceas for medical education. Just because a thing sounds logical does not mean it will work. Indeed I worry that revolutionary adoption of some of the ideas in an extreme form might weaken the morale and traditional strengths of our schools.

Selection from a Broader Educational and Social Base 

It is fashionable to suggest that the medical students we now select have not a sufficient breadth of education. I would be surprised if they ever had! However, to overcome this the report suggests that premedical education should cover not just the natural sciences but the social sciences and the humanities as well. Off the cuff, I suspect that most of us would side with the angels and plump for a broad rather than a narrow education. But on reflection it is not that simple. A study in the breadth suggested could make exposure to each area so superficial that its educational value would be worthless. To produce a good musician, you do not attempt to teach him every instrument.  Similarly, you will not produce a good scholar just by exposing him to a little of everything.

I understand the thinking behind the recommendation, however. There is worry that the college efforts of intending medical students are geared excessively to excelling in physics, chemistry and biology to the exclusion of other subjects. Personally, I do not worry too much about that. The best way to learn about learning is to study in depth and it is not impossible to teach the liberal arts through the sciences. Biology, for example, has a history, a geography, a literature, many languages, a mathematics, and a philosophy – not to mention social and ethical implications. There is no reason why a good biologist need be narrow intellectually. For educating the mind, the rapport built between teacher and student may be more important than the subject taught. Exposure to many teachers in short courses covering most of the disciplines taught within a university is no guarantee of a good education if no teacher has time to make much impact.

In advising medical schools not to make entrance requirements too restrictive, the report questions whether medical students need a scientific background to benefit from the course. Many newer schools believe they do not, and may be correct provided the students are bright and motivated. However, I suspect that lack of a science vocabulary must be a handicap for the average student in coping with the average medical course and I advise intending medical students accordingly.

It is popular to argue that students from disadvantaged minority groups should be selected to provide an appropriate mix of medical manpower and to correct social inequalities. The report puts it this way: “Continuing effort is needed to increase the opportunities for under-represented minority students to be prepared for medicine in college and matriculated in medical school.” I accept that, but feel that medical schools should not compromise their standards, courses, or procedures to do so. I see medical schools as places providing medical education of an acceptable standard to all students qualified to benefit from it. I do not see them as instruments for social engineering and my experience suggests that those who do, pay heavily for it in educational and human terms.

Selection on Personal as Much as on Academic Qualities

There is a theory that the medical students we select may be too single-minded and too clever to be good doctors and that they do not possess the human qualities and independent learning skills that future doctors will require. My trouble here is my uncertainty about identifying, let alone measuring, the personal characteristics required to be a good doctor. Like everyone else I have my prejudices on what they are but, unless I’ve known someone for years, I cannot be certain they possess them. Even if a psychologist assures me that they do, how can I be certain they will retain them in later life? Personal characteristics are easily simulated. I have been saddened by the mental dishonesty adopted by some candidates as they simulate the attitudes they believe are needed for selection. Inwardly I sometimes cringe when I read those awful essays written by otherwise bright and honest students on why they want to become a doctor; how they had this sudden call as a child to heal the sick and splinted their teddy bears’ broken legs. Any system that encourages pretence and mental dishonesty is a poor screen for medicine.

I am happier to base selection on objective measures of academic performance. I do not believe there is an inverse relationship between academic skill and humane values. If students do well academically, they must be reasonably bright, reasonably determined, and have reasonable mental and physical health. Can we ask for more? Within the diversity permitted by such objective selection should be most of the qualities that doctors might need in the future.

What worries me even more is the tendency of some of the newer medical schools to recruit staff on the basis of their beliefs and personal characteristics rather than their academic performance. If it is decided to start a new medical school with a particular new philosophy that emphasizes certain personal characteristics, a dean will be found who espouses that philosophy. To prevent the philosophy being subverted, foundation staff is recruited that shares or pretends to share those beliefs. An emotional commitment to the belief or philosophy then becomes more important than academic merit when appointments are made. Anyone who criticizes the school credo risks being branded a dangerous heretic or disloyal to the pack. To some extent it’s like joining a monastery; one must subscribe to the institutional beliefs to belong. The only real way to question the belief is to resign. I would prefer to work in an institution that will tolerate all varieties of belief and where the only credentials for membership are academic ability and integrity.

“Emphasis on Principles Rather Than Facts

There is a widespread belief that students spend too much time memorizing facts and that we should reduce scheduled teaching time and the amount of material we expect them to learn. Superficially this is attractive but it worries me for the following reason. I do not think we can understand anything well unless we first take the trouble to immerse ourselves in the facts. Initially, they may seem confusing and disconnected and the subject as a whole may not make sense. Though this is a depressing phase, it is important to learn to press on. If we keep grinding on, the pertinent facts drop into place eventually, and the subject as a whole begins to hang together. Concepts emerge. It is a very rewarding and exciting intellectual experience, when, as we say, the penny drops. The length of the latent period between beginning to study a subject and beginning to understand it varies, but in my experience is rarely less than six months.

I have tried repeatedly to discover ways of helping students contract or even bypass this latent period; it would so accelerate their education. But I have never been successful. To know a subject, it seems one must first put the facts that underlie it into one’s head. Using other stores such as floppy discs or library files is no substitute for mental assimilation. And, of course, our heads, especially when they are young, are superb at this, considering the vast amount of new information poured into them every day. What’s wrong with memorizing material? We all do it. When examining a patient one should go through an orderly series of drill-like procedures which have been memorized with precision; if one is to be thorough (let alone make a diagnosis), one shouldn’t work out the conduct of each physical examination by going back to first principles each time. People say, why memorize facts when one can look them up in a textbook or on a video display screen? That is as foolish as saying, why memorize words when they can be looked up in a dictionary? It would be virtually impossible to think or speak if one had to look up every word. Similarly, one can do little in medicine (or anything else for that matter) without a large store of working information in one’s brain.

Facts are the only constant reality (though some are more useful than others). Concepts and principles are necessary but they are merely theories to relate a set of facts and are usually ephemeral. Though concepts may seem more exciting than facts, they are no stronger than their factual basis. Take the analogy of the results and discussion sections in a scientific paper. The results section should give the unadorned findings or facts in a disciplined way that should be as true in 100 years’ time as it is today. In the discussion section one can hypothesize and elaborate concepts to relate the facts to the heart’s content. But, one can and must abandon these concepts when new facts emerge that don’t fit. A person whose knowledge is of concepts only, lacks the database from which to question the concepts and, if necessary, develop new ones. David Lagunoff, in a recent letter to the Journal of Medical Education, could not have put it better. He wrote:

“Medical students need facts; they need a well-developed medical vocabulary and an orderly conceptual framework to create the intellectual context in which reasoning and problem solving become possible. The most astute reasoning is quite useless if it is not carried out in the context of facts.”

“The Information Explosion

It is fashionable to talk of the “information explosion,” that suggests that knowledge and the amount we require our students to memorize is increasing exponentially. This sounds reasonable but it is not quite like that. I had a great-great-uncle who was one of the first students at our medical school in Belfast about 130 years ago. He was awarded a book prize in physiology on the results of a first year examination in chemistry in 1858. It is a splendid, heavy, leather-bound book which I admired greatly as a child. I can remember thinking how clever doctors must be to know so much. Later, after I read physiology, I began to wonder how so much text could be written at a time when so little was known about physiology. Would, for example, this great tome say nothing about the adrenal cortex on the grounds that nothing of its function was known? Not so – the section on the adrenals was longer than in most modern student texts; it described in detail the structure, blood supply, nerve supply, comparative embryology, and comparative anatomy, hypothesized about this and that, and built up the concept that it might add “nutrients” to the blood. The number of facts to be memorized by the student then was as great as, if not greater, than it is now; the difference today is that a more pertinent set of facts is presented to the student to allow him to see the present-day concept.

In another 130 years I suspect that we will not present the student with more facts about the adrenals, merely more relevant facts to give him the concept of the gland that is fashionable then. This brings us again to the crucial importance of good teaching. From the countless facts available of varying relevance, a teacher must guide students towards those which permit the formation of concepts and if necessary their modification in the light of new knowledge. The teacher does not do the students’ work for them, merely points them with the appropriate facts in the right direction.

Information Technology

In all branches of learning today, and medicine is no exception, it is fashionable to argue for better “IT”; in other words, “information technology,” to deal with the “information explosion,” and that students should have instruction in its use. To me, there is little fundamental difference between storing information on floppy disks, notebooks, or card indexes and I would give training in the use of computers no more or no less emphasis than I would give to training in keeping good records or in the use of libraries. All seem useful technologies that can facilitate our work. The important thing, it seems to me, is to limit the time wasted by students learning ephemeral skills. I find that as soon as I learn one way of communicating with a computer, they change the language (if not the computer). At one time, people convinced me I should learn the electronics on which medical technology depended. So I spent many happy but rather useless hours constructing a radio from resistors, capacitors, etc.  But I was weak on electronics; my radio crackled quite a lot (perhaps because of cold solder joints), and soon my fledgling skills were made obsolete by the introduction of printed circuits. I suspect that doctors should not divert too much time to rediscovering the electronic or computer wheel but should use electronic and computer experts to provide the services they need.

Emphasis on Acquiring Attitudes and Skills as Much as Knowledge

The theory here is that having the proper attitudes, values, and learning skills may be more important than knowledge to doctors of the future and should be stressed accordingly. What about teaching attitudes? Attitudes are important but are difficult to teach systematically without evoking cynicism. You may know of the disadvantaged boy who, when asked to write an essay on police, wrote, “Police is bastards.” His teacher, worried by this negative social attitude, took him to a kindly police sergeant who explained at length the social role of the police in protecting the weak, helping the young, and so on. In his next essay on police, the boy’s teacher was depressed to see little improvement; all he had written was “Police is cunning bastards.”

I suppose the only way to teach attitudes and values is by example. Medical students are as perceptive as the youth at the police station, and if they detect a difference between what people say and what they do regarding attitudes and values, they become cynical and their cynicism is justified. It comes back to the crucial factor in education, the quality of the teachers. If the attitudes and values they exhibit through their work are what we would wish, we do not need formal teaching to inculcate them.

Can we teach skills? We can teach people how to do things. I am not sure we have time to make medical students very skilful at anything. For me personally, skill only comes when I have done the same thing over and over and over again until I am almost sick of it. A person can be taught to row in an afternoon; it takes years to make an oarsman. So I do not worry much if medical students leave me with only rudimentary skills. They have their whole professional lives to perfect the skills I would like them to have if they are to practice on me in my old age.

It might be good educational practice to teach each student to develop one skill to a high level. This might show that nothing is very easy and that to do anything really well needs hours and hours of practice. Learning this lesson could be important for people whose appreciation of skill may determine what they do, or more importantly don’t do, to their patients.

Emphasis on Teaching the Medicine of the Future Rather Than the Medicine of the Past

The theory underlying this recommendation in the report is that since our students must work in the future, there in little point in teaching them the medicine of the past. It is hard to object to this since students who work in the future will find that the incidence of disease and the way it is treated change continually. It raises the important issue, pertinent to all education, of how to train people for work in the future. It is very hard to teach a satisfying course on material where we know virtually nothing. The future falls into this category and it is difficult to teach about it in a meaningful way. I suspect the only useful way to help people cope with the future is to illuminate the past. The past is all we can speak about with authority. If, by doing this, we can show that medical knowledge was seldom static but kept evolving as new techniques gave new opportunities; that problems arose continually and were often overcome; that new ideas kept bubbling up but virtually all proved useless, we can explain where we are today and how we got here. Then we can leave it to the young themselves to carry medicine forward. If they watch us adapt to today’s situations and uncertainties, when we fail as well as when we succeed, and see how we draw on lessons learnt from the past, they will learn the tricks and attitudes needed to deal with the unknowns of the future.

Teaching through research is particularly useful here since it gives insight into the thinking needed to solve problems. Here is another reason, if one were necessary, for having the best possible teachers – people for whom solving problems through research and adapting to new situations is second nature; whose attitudes will be as appropriate for work in the future as they were in the past, with a feeling for excellence, hard work, common sense, clear thinking, and above all, intellectual honesty. If such teachers can by their example pass on to their students the ability to think with honesty and sim­plicity, we needn’t worry too much for the future.

It is often said that the medicine of the future will have more to do with health education and preventing disease than with curing disease and that our courses should stress this. This is not a new idea and most of us would support it. I wonder why courses in health education and the prevention of disease are not more successful and popular. Perhaps they don’t fit so easily into the Hippocratic tradition of a one-to-one relationship between doctor and patient. I don’t see overt resistance in medical schools to teaching health education; I suspect it is just a difficult course to teach well.

Emphasis on Teaching Community Medicine as Much as Hospital Medicine

Since most encounters between doctors and patients do not result in attendance at hospital, the report advises that medical education should concentrate on medical work in community settings. This is sound advice yet hard to execute in practice. It is so much easier to monitor standards of medical care in hospitals than in community settings. There is little merit teaching in situations where standards of medical practice are not inspected and approved by faculty. To work well, the staff in community-based medicine and the courses they run must be no less exacting in their standards than those in the hospital-based specialties, and I suspect that it will take time to get it right if only because of the considerable logistic, financial, and other problems. Nevertheless, this is an area where there has been enormous improvement during my academic lifetime. The setting up of university departments of family medicine (general practice), geriatric medicine, mental health, and so on and the appointment to them of staff of first rate ability has transformed the perception of these branches of medicine in the eyes of our students (and perhaps in the eyes of some of our more conservative staff).

Medical Education Should Be Faculty-based rather than Department-based

The report reflects the widespread feeling that many departments are not really interested in teaching and teach all the wrong things in too great detail (especially pre-clinical departments).  Most of us could think of examples to support this. However, it is sad when departments lose responsibility for their teaching since experts in a discipline should know best what contribution their subject can make to the medical course as a whole. Departments should know of the weaknesses and strengths of their own teachers and field these to the best advantage. Departmental teaching should permit better integration since one departmental member should know what the others are meant to be talking about and so reduce overlap or omission. When departments organize teaching it should be easier to provide cover for teachers who are ill or on leave. I like to see departments compete with one another to show their subjects in a good light, even if their motivation is only to encourage students to come back to work there later. I like to see them kept on their toes.

Taking responsibility for teaching away from departments is likely to diminish their interest in teaching. Their role in training their own staff in teaching skills is undermined. The groups within faculty who take over responsibility for the organization of the teaching program may not consist of the most prestigious or influential people in the school and this may damage the school’s perception of teaching. This, I think, is the crux of the problem. I would like to think that all faculty members should carry some obligation to help plan and deliver student teaching. I do not like to see this important duty left to a small caucus of self-selecting education specialists within faculty.

Medical Education Should Be Integrated Rather Than Subject-based

Though integrated teaching is widely perceived to be a “good thing,” and the report comes down on its side, there is often a yawning gap between theory and reality. Almost everyone pays lip service to it yet most people in my experience (except those responsible for it) are not entirely happy with it. I suspect it can be done well if one has enough time, enthusiasm, and resources, but it is not easy. Integrated teaching can be extremely time-consuming for the organizers and the teachers (they spend a lot of time in committees) and confusing for the students who have to grapple simultaneously with the different intellectual approaches of a variety of people in different disciplines, and it is bad for departments by removing their responsibility for teaching. Managerially, an integrated curriculum is a complicated curriculum and can result in bureaucratic inflexibility. The philosophy and scientific basis of an individual subject cannot be developed well in an integrated setting, nor is there time to develop historical themes which to me are very important in education.

Staging integrated topic teaching requires enormous managerial skill: marshalling troops, conducting briefing and debriefing sessions, making sure speakers do not contradict one another too much or overrun their times. Even then, the student may only get a series of disconnected mini-lectures lacking a cohesive intellectual theme. The presentations may overlap in content if the presenters do not know which of their points will be made by others. When everyone has spoken and the final panel discussion draws to an end, the show may have outlasted the willingness of the audience to listen. We always hope that next year will be better, but fate may frustrate us if the curriculum committee changes the topic or the organizer goes on leave. It is not for the faint-hearted.

Though subject-based teaching can distort proper balance, integrated teaching has much greater capacity for distortion. For most topics, certain disciplines have much greater relevance than others and to give them equal emphasis may not be helpful.  To the outsider, neuro-anatomy and neuro-physiology seem obvious candidates for integrated presentation, yet the educational case for doing so is not convincing. Neuro-anatomists and neuro-physiologists can take completely different intellectual approaches to their subjects and to juxtapose the presentations can confuse the student. Neuro-anatomists may see the brain as a structure of beautiful and incredible complexity and describe it as such. The neuro-physiologist might prefer to see it as a black box and find the shapes so loved by the anatomist a confusing distraction.

In the end, each student will have to integrate the knowledge he gathers from many sources in a way that makes sense to and satisfies him. What better integrator could he have for this than his own well-trained brain. If he becomes adept in using it, he will find it a very useful tool to cope with the confusion and anarchy of the real world.

Medical Education Should Be “Active” Rather Than “Passive

The report stresses that medical knowledge is changing so quickly that a student who cannot learn independently will not be able to keep up after he leaves university, unless he has learnt to learn by active rather than passive means.

My problem with the active/passive concept is that the only learning I know of is the active variety. If there were a technique for “passive” learning which put material into my head at no personal effort, I should use it all the time. It is an effort for me to learn anything and I am grateful for any assistance. For this I will use all the “teaching aids” available, be they books, lectures, diagrams, video-cassettes, or, best of all, people who really know what they are talking about. These people are the rarest and best teaching aids and are in heavy demand. It is best if you can have a one-to-one relationship with them but, since there aren’t many to go around, it may be necessary for us to form groups to listen to them (say at a lecture) or else read their books or other publications individually.

Though these rare people were crucial in helping me to learn in what some might call a passive way, it did not feel passive at the time. My poor brain is easily confused and I had to keep thinking very hard about what I was being told, writing it out and asking questions before I could really come to grips with the material. So I am grateful to people willing to give time for lectures, talks, and writing to assist my learning process. If they were my teachers, I would be sad if they reduced the amount of scheduled time they were prepared to give to help me learn. I need all the help I can get. Left to my own devices without people to explain things to me, I don’t think I would have got very far, nor perhaps would any isolated member of the human race.

Tosteson (1979) made an important point that fits with my experience. He said that people, when asked about the most significant event in their education, usually did not mention a particular course, subject, book, place, or idea. No, in nearly every case they mentioned a person. It is people, not video-cassettes that really influence our mental development. A word – and an honoured word – for such people is “Teacher,” and they are the most important ingredient in the whole educational exercise. I do not think we should feel ashamed of wanting to influence our students through teaching. To prevent students being helped by good teachers seems nonsense and contrary to all human history. Independent learning, whatever that may be, can only be a pale and lonely substitute for learning from good teachers who have spent their lives working at and adding to the subject they love.

I cannot see that good teaching would limit a student’s ability to learn independently in the future and make him mentally lazy. I suspect that it can only increase intellectual curiosity and vitality, which one hopes may be passed on to others. Conversely, in my experience even the most sophisticated and enlightened teaching programs are worse than useless if they are taught or administered by apathetic or disinterested teachers who do not know or love their subject well.

Evaluation Should Be Subjective as Much as Objective 

The urge to switch from objective examinations to subjective evaluation of performance comes from the theory that most examinations test only memorized information and not learning skills. Personally I do not follow this since I suspect that you need to develop learning skills even if only to memorize information. The report states that “standardized examination cannot replace reasoned analytical personal evaluations of the specific skills and overall abilities of the student.”  I suspect the person who wrote that hadn’t much experience of grading large groups of students. Grading a person by what he looks like, says, and does is as fraught with difficulty as attempting to select students by the same method. I have not found it very reliable as judged by the different responses a single student can evoke in different members of staff. I suspect that students, who have a strong feeling for fairness, would want the criteria that determine progress to be reasonably objective. If I were an outsider inspecting a medical school, I would put more weight on an independent objective assessment using objective criteria than on any number of in-house self-evaluations.

Evaluation Should Be Continuous Rather Than Periodic.

Some people feel it is unfair to subject students to the emotional stress of important end-of-course examinations in which their progress will be determined based on their ability to reproduce samples of their knowledge.  Some consider it kinder to evaluate students by continuous subjective assessment. Unfortunately, with this type of assessment, someone has to watch each student near-continuously to make sure they are doing what the watcher wants. As a system I would hate it. I would prefer to know the objectives required by faculty and have the freedom to meet these in the way that seemed best for me. I wouldn’t want my future left in the hands of a faculty member with whose approach to life and work I mightn’t agree. I think there is substance in Pickering’s criticisms of continuous assessment: (a) If it is properly done, it takes up an enormous amount of staff time, (b) It is virtually impossible to exclude personal bias from the ratings, (c) It does not permit comparison of standards across institutions or countries, and (d) Being continually assessed may cause unnecessary anxiety for the students.

My greatest worry about it is that making the teacher a constant assessor turns him from being the friend, to help the student learn, into a Big-Brother monitor. The teachers and the taught are put on opposite sides of the system and communication between them is undermined.  I quite like our own arrangement where the teacher’s role is to help students reach the national standard required by the licensing body. External examiners are brought in to ensure we maintain these standards in our end-of-course assessments, and our role is to help the students to satisfy these examiners.

Steps Should Be Taken to Define Objectives 

Most of us would feel that students should know what they are expected to gain from attending a course and several recommendations in the report urge us to define clearly the objectives of our courses. Few would quarrel with that. Students’ anxiety is reduced when they know what faculty expects of them, and it helps them to study. However, unless done with imagination, objectives may become a boring checklist, an imprecise paraphrase of the list of contents in the recommended text. Am I alone in finding lists of objectives so boring to read and to prepare, a tiresome exercise in pedantry? Perhaps I have never come to terms with educational bureaucracy.

Steps Should Be Taken to Increase Resources 

There is a theory that most of our difficulties are due to lack of money; that if we had more money for teaching we would teach better and that if we had more research money we would do better research. It is a fashionable cry from those who, like myself, are well-practiced in spending public money. However, a lifetime in an education system supported almost entirely by public money has not convinced me that this is always true. In my 30 or so years in the business, our staff-student ratios have improved dramatically, the number of our technicians has gone up exponentially, our department is housed in an imposing medical centre instead of in huts, our departmental expenditure is greater in real terms than that which used to support the entire medical school. Yet I am not sure that our teaching is much better, our research is any more exciting, our sense of purpose is any greater, or indeed if we are any happier. With so much plant and personnel to look after, I, as a departmental chairman, spend more time on managerial matters than on the teaching and research I enjoy so much more.

I suspect that the university bonanza of the sixties and seventies has given us more apparatus, people, plant, and buildings than most of us can manage properly.  So perhaps I should not join in the chorus for more money from the state. State spending systems tend to encourage waste and may eventually enslave us. I would be happier for the moment making better use of the money I have and, if more is needed, to see how I can earn more from what I do. If no one is willing to pay for what I do, maybe I should be looking for other work. I am not sure that the statement, “undue dependence on faculty generated money inevitably affects educational quality,” is always true. It could promote relevance.

While saying that, I still feel that some protection of academics from day-to-day and year-to-year financial pressures is essential. Medical research is a tender plant and needs sympathetic patronage. It is prone to wither in a hostile environment.

Steps Should Be Taken to Promote Literacy

There is widespread concern that many young doctors cannot write well and lack the language skills needed to think clearly. I don’t know whether or not this is true, but I would still give this recommendation in the report wholehearted approval. It is the key to all education. The only way I know for us to promote it is by giving an enormous amount of time to correct and correct again the literary efforts of ourselves, our students and our colleagues. No one likes having their prose corrected and few of us like to give so much editorial time for such thankless work. However, there is no doubt that the main difference between good writing and bad writing is the amount of time and effort that has been spent on it. Writing is a hard, highly disciplined craft that requires constant practice to maintain quality. It is also a skill where we should all be humble because we have much to be humble about.

Many of us as teachers set bad examples. The Journal of Medical Education is not free from verbosity; ideas may be drowned in words and many words are often used where one would do. How can we expect our students to write and think clearly if we write in the style of the following summary taken from a recent paper in an educational journal:

“The authors in this article have described the attempt of one department of family medicine to develop and evaluate a required clerkship which replicates the ethical totality of the patient-family physician relation in effective clinical practice. Special attention has been given to the methodological problem of balancing clinical integration and systematic integrity in such a way as to preserve both the relevance and rigor of ethics in clinical education. A rotation involving both the private practice and academic clinical settings has been combined with an intensive interdisciplinary seminar to develop an appreciation, understanding, and utilization of the biomedical, psychosocial, and valuational components of responsive and responsible ambulatory care.”

Another example of indifferent modern scientific prose from a government publication has kindly been brought to my notice by a former colleague, John Shepherd, who now works at the Mayo Clinic. It concerns an empirical classification of U.S. medical schools by institutional dimensions and reads:

“Based on the result of the six factor hierarchical cluster analysis, an optimal solution was sought using Forgy’s non-hierarchical cluster analysis method. The results of the hierarchical clustering were used to give an indication of the number of clusters which would represent the schools, and schools were selected as seedpoints for the non-hierarchical cluster analysis based on the hierarchical clusters. In the hierarchical cluster analysis, one school, the Mayo Medical School, appeared so dissimilar from the other 109 schools that it was not included in further comparisons. The Forgy non-hierarchical cluster analysis technique complements the Word hierarchical method by optimizing the same criterion, the sum of the squared distances of the schools from the cluster centroids, but does not maintain the permanence of cluster membership inherent in the hierarchical methods.”

It is enough to make Flexner turn in his grave; Flexner’s report should be required reading for everyone who wishes to write (and think) in medicine. Part of the problem with writing may be that we love our own words so much that having written them down, we cannot bear to throw them out. I suffer from this myself. John Shepherd made me aware of the problem and how he was helped to overcome it. Again, it did not come from attending a course on “How to write good English” but through exposure to the mind of a great teacher. In his early postgraduate days, John produced a magnificent thesis for a certain examination. It was magnificent not only in its findings but in its bulk, with its many fine diagrams and tables. After he was awarded the degree (for which incidentally he also received a gold medal), he decided to publish the work. It split conveniently into several sections, each of which he submitted as a separate paper to Clinical Science.  George Pickering, who was editor of Clinical Science at the time, explained to John how the work could be described with more clarity and force if it were condensed into one short paper and he re-wrote the papers in that form for him. He showed him how to leave out all the words, tables, and pictures that only obscured the central story.  One of the pictures to go was a photograph of an ergometer John had designed and built himself and to which he had a strong emotional attachment. Pickering said it was a nice picture that gave some idea of the architecture of the room but little else! This is, of course, very painful stuff at the receiving end but that is what education is about. John Shepherd has had a lasting affection for Pickering, who went to so much trouble and took so much time to help a young author. In my turn, I owe an enormous intellectual debt to John Shepherd, who passed on something of this experience to me. To write briefly is much harder than to write at length, and we cannot blame our students if we set examples of verbosity for them to follow. The hallmark of the scholar should be Flexnerian literacy. Sentences should contain no unnecessary words and paragraphs should have no unnecessary sentences. If there is nothing worth saying, one should stay silent. What better cue to stop?


The GPEP Report worries me a bit since it seems to embrace most of the educational fashions of our times whose efficacy in educational terms has not in many cases been proven. Though I am all for an open mind, I think we should look askance at most new educational theories, no matter how fashionable, in the near-certain knowledge that they are no more (and probably less) likely to be correct than our present ones. No system, no matter how ingenious, is any use if it doesn’t work. We would be wise in general to use only those systems where there is a prima facie case that they have worked successfully elsewhere over a period outlasting the enthusiasm of the launchers. There are few prizes and many penalties for being first in medical education. Schools that follow usually do better by benefiting from the trail-blazers’ mistakes. Perpetual change for change’s sake can undermine morale and efficiency in both students and staff and will make systematic analysis of the effects of change impossible. Evolution seems preferable to revolution as the normal means to progress; there is plenty of time. We do not need to hurry or panic about the year 2000; it is just a number and there are plenty of higher ones. In any event, what the curriculum contains and how it is organized is of much less importance than whether it encourages strong personal bonds of affection and respect, if not love, to develop between the teachers and students and teachers in different disciplines. Only in this context is real education possible. In a medical school it is the people who work there rather than the form of the curriculum that will determine in the end whether it is a good or bad school. I think we would be wiser to channel our efforts to improve medical education into ensuring that the best possible staff will wish to come to teach and research with us rather than have just one more attempt to set the curriculum on its head.



'University students'

Clichés in Medical Education

(To see a comment regarding this article go to the 14th April 2014 blog)

Although this article was originally published as a series of shorter pieces in The Lancet in 1984 I have written it out here in full.

People in my position have a problem. Though we are medical teachers in that we have taught medical students for many years, we are not experts on medical education. Though we cannot explain in educational terms, we have developed an instinct for those approaches in medical education that might work and those that might not. It is this instinct that makes us react so negatively to the clichés used by people who work in theory rather than practice of medical education. In the past year I have visited medical schools in many countries and have been struck by the widespread concern that damage might be done to medical education by ill-considered acceptance of new ideas. There is the fear that the neo-educationalists may not accept evolution as the normal process for change, but press for revolution to exercise their theories. This experience has given me the incentive to jot down some of the replies I ought to have made when the following clichés were first put to me.

In an ideal world, medical education would be a totally integrated and multidisciplinary experience

One feels rather lonely when attacking motherhood, patriotism, religious zeal, or integrated medical education because of the widespread belief that they are good things.  My cynicism in these matters of faith may stem from my country of origin. Though we are encouraged by the General Medical Council green book to introduce “integrated and interdisciplinary teaching throughout the undergraduate curriculum”, I do not find the advocacy for this very convincing. In my experience, integrated teaching is difficult to plan and to mount; is extremely time-consuming and time-wasting for the organisers and for the teachers; is confusing for the students who have to grapple simultaneously with the different intellectual approaches of a variety of individuals and a variety of disciplines; and is harmful for departments since it removes from them their strongest stimulus and raison d’etre, the responsibility for their own teaching.  I think the time has come to face reality. So much effort and time has been given by so many medical schools to promoting complete integration with so little success that the onus of proof for its viability must lie now with its protagonists. Until they can demonstrate an acceptable model of the system working satisfactorily with the resources available and over a period that outlives the enthusiasm of the launchers, academic staff should not have their time needlessly dissipated in attempting the impossible.

If what I have said is correct, what can explain this pervasive drive towards an illusory goal? Part of it may be our natural wish to meddle in the affairs of others and exercise power over them. We are all victims of fashion, and integrated medical education is certainly fashionable. Another factor may be the suspicion that the other fellow is using too much of the students’ time telling them about his subject when it could be better spent learning about ours. All the natural forces work against integration and schools with integrated teaching tend to revert slowly to teaching by discipline. This tendency is recognised by medical schools that advocate integration and some of them fight vigorously to combat what they refer to as “the regrettable tendency to revert towards the mean”.

My experience suggests, despite the views of many educationalists, that the best people to decide on what is appropriate to teach to medical students about a discipline are the experts in that discipline. I cannot prove that I am right in this, but such is the stuff of educational debate that they cannot prove I am wrong.

The harmonious and balanced teaching that we all seek will not be found just by setting up yet another curriculum review committee. It requires the constant dialogue and consultation between staff and students in different disciplines that stem from mutual affection, trust and respect and a common concern to foster the knowledge, skills, and mental attributes needed for a life-long career in medicine. Merely talking and listening to one another should rid teaching of the most glaring examples of repetition, lack of balance, omission, and mutual incomprehension that creep in when teachers and students fail to communicate. In the last analysis, each student has to integrate his or her own knowledge and experience drawn from many sources in a way that is helpful and satisfying for the individual. What better integrator is there for this than the individual’s own brain?

We should have more mature students

Why? Because it is fashionable? Perhaps.  Because being older and wiser they do better in their examinations? No, they do less well.  Because they use their earlier specialism as an adjunct to their medical practice? No, they usually become general practitioners and do not use their earlier speciality. Because it makes economic sense? No, it does not make economic sense since they can spend fewer years in medical practice after qualifying. Because they give a mature point of view and variety to an otherwise rather homogenous class of eager school-leavers? Yes, certainly. I do not know how to draw up a balance sheet for these arguments and I suspect nobody else does either. Perhaps that is why we admit about 10-15% mature students to our schools, while we wait for more evidence on the matter to build up.

Students should not be taught; it makes them mentally lazy. They should discover their own areas of ignorance and respond appropriately

Perhaps the reason I find this so hard to accept is my enormous sense of debt and gratitude to the splendid teachers who shared with me the accumulated wisdom they had built up from years of experience. I do not think it made me mentally lazy; in fact I think it opened my mind to all forms of curiosity and adventure. I really enjoy listening to someone who knows his subject intimately. No matter what his subject maybe, if he loves it (and I can tell if he loves it) he can give me an insight into how his mind works and what the subject is really about. If I am lucky I can share his excitement in it. No matter how outlandish it may appear to be, if be loves his subject that much, I feel it cannot be all bad.

One of my daughters had a rather bad time with self-discovery in lenses. She was given lenses, mirrors and light sources and encouraged to recapitulate the discoveries of Galileo as part of her course in ‘A’ level physics. Though she was acutely aware of her ignorance in lens matters, she lacked Galileo’s genius for seeing solutions. What she needed was someone like Galileo to explain lenses to her with the knowledge, confidence and enthusiasm that comes from years of thought applied to a difficult problem. I accept that this might have made her mentally lazy but, on the other hand, it might have so excited her and fired her imagination that she would have devoted the rest of her life to laser technology. As it turns out she still does not know much about lenses and I do not think she even likes them very much; but then she has a wonderful teacher for chemistry and that is the subject she really loves.

Medical students are getting too clever to be good doctors: they should be selected for their common sense and compassion rather than for their intelligence

I have heard many doctors say that with the entrance standards required today they would not have got into medical school.  I could say the same myself, but I think we are being too modest. We did the trifling amount of work that was needed then for acceptance, but if the hurdle had been set higher we might well have done the additional work needed to clear it.  We will never know. Actually, I doubt if medical students today are much more intelligent than they used to be. Again we will never really know, but my impression is that many students get to medical school by dint of hard work, determination, and expert coaching as much as by intellectual ability. Despite the narrow range of attainment as indicated by GCSE ‘A’ level scores, each year contains a wide range of ability from the supremely intelligent to the relatively stupid. Examination results do not reflect intelligence only; they also reflect determination, stamina and physical and mental health, qualities that are particularly useful for busy medical practice.

I am open to conviction, but I am not certain that unintelligent doctors are necessarily good doctors, or that they should have a larger measure of innate compassion than their intelligent counterparts. Compassion requires the imagination needed to put oneself in another’s position and intelligence should help develop such empathy. Some of the most intelligent people I know are also the most sensitive and compassionate. Of course, this is an argument that we can never really settle, since we cannot measure compassion. It is often born of experience, and looking back on the people in my own year I am surprised that some of them who seemed particularly callous in their student days have turned into such kind, caring and sensitive doctors. A retrospective analysis of the careers of these people would suggest that even if prospective medical students showed evidence of compassion at their interviews aged seventeen, there is little guarantee that it would still be evident when they were thirty-five, and vice-versa.

The good thing about examination results as the criterion for entry to medical school is their objectivity. The system is a fair one and the candidates (and their parents!) see it as fair. Most people who make the grades must have a reasonable measure of physical and mental health. Other systems of selection are much more subjective. My trouble with interviews is that I tend to prefer people who think like me and share my interests, especially girls, though in my less egotistical moments I know that to cast all future doctors in my image would not be good for medicine. I also find it difficult when I have interviewed more than 200 candidates to remember whether candidate 147 was better or worse than candidate 35 and, with me, such retrospective decisions tend to be arbitrary.

I am happy to see students admitted to medical school on objective evidence of their intelligence and determination and hope that maturity and emulation of their teachers will engender the sensitivity, understanding and compassion needed for dealing with patients and their relations. 

It is every bit as important to teach medical students how the mind and society work as how the body works

This is a noble sentiment that was advocated in the Todd report (Royal Commission on Medical Education 1965-1968. London: HMSO, 1968).  Furthermore, it is one to which no reasonable person could take exception. Why then does it not work? My theory is that it is never good teaching practice to spend too much time teaching about things we do not understand. We all have to do it sometimes, but medical students are very perceptive and can tell when we are overdoing it. I suppose if we really knew how the mind worked or how society worked we would have courses on these subjects as the main planks in our curriculum, especially since we know how much disorders of the mind and society can contribute to the clinical problems we see. Maybe in the distant future we will have a body of knowledge in these areas that is worth teaching, but until we do I am afraid we will still be plagued with the negative reactions that their teaching usually arouses in our students.

It could be argued that there are many aspects of how the body works that are as little understood as the workings of the mind and society. This is true, but we do not concentrate our teaching on those aspects. If we did, the responses might be just as negative as those usually meted out to the behavioural scientists and sociologists. However, we tend to concentrate on those areas where there is enough scientific evidence to make our case. I do not spend too much time teaching about the mechanism of sleep or how electrical impulses are turned into mental images and stored in the visual cortex, not because they are unimportant but because I do not understand either process. I am sorry that students find negative knowledge so dull since I feel that it is important for them to know what cannot be explained scientifically as well as what can. But if I dwell on the unknown for too long, the students complain and ask why I teach physiology when I know so little about it. Not a legitimate question really, but I bow to their pressure.

Happily, this does not mean that our medical students need graduate with no understanding of human relationships and behaviour or with no feeling for the faults in society. The traditional medical course with its strong emphasis on practical training at the bedside, in the outpatient clinic, in the general practitioner’s surgery and in the home provides the opportunity for students to learn about grief, sorrow, happiness, poverty, love, hate and all the complexities of human behaviour, not in a theoretical way but in real life. They can watch their senior clinical colleagues who have little theoretical knowledge in these areas interact with the patients they treat in a manner that is born of years of experience rather than culled from badly written textbooks. The experience as an intern is one of the most educational of all in this respect, since the practical training goes hand-in-hand with responsibility for dealing with patients’ fears and worries and the anxieties and sorrows of their relatives. One should not forget how much medical students learn about human behaviour by observing one another in their five or six years of common endeavour. In fact, I do not know of any course that teaches more about human behaviour at all its levels than the traditional medical course.

Anatomy is largely a waste of time: most of what we learn we forget

I am glad to say that this cliché is heard less frequently now than about fifteen years ago. However, in its time it did considerable harm to an important subject. What people who say it forget, is how much they use and rely on anatomical vocabulary and thought in their everyday lives without being aware of it. When a word such as “pancreas” crops up, a picture of a flattish yellow gland at the back of the abdomen floats into our consciousness, together with its ducts opening into the second part of the duodenum. As our mind focuses down on the imagined histology, we can even see the little clusters of cells making up the islets of Langerhans. This information was not put into the mind by the genes; it came from reading and work in the dissecting room. Teaching physiology to science students, who have not had the benefit of an anatomy course, is much more difficult than teaching physiology to medical students, since the vocabulary that doctors use naturally with their anatomical background is strange to pure scientists. It is hard to realise that for some people “spinal cord” and “spleen” are nothing more than words.

There is also a pleasing rigour about anatomy as a mental discipline. It is not possible to have too many theories about the sites of origin and insertion of skeletal muscles. They begin and end with a precision not often found in other disciplines. If one’s thinking about them is not right, it is wrong. There are not forty shades of being right. Thus, it has a value in mental training similar to that which medical students used to get from learning Latin and Greek. The beauty and precision of these languages inculcated neatness, precision and logic in thinking which are extremely useful in medical practice.

Finally, learning anatomy provides good practice for the brain to store large amounts of information and teaches the student the mental tricks and strategies for doing this. We do not have to fear that if we learn too much anatomical detail there will not be room for anything else. The mind seems to have a virtually limitless capacity to store information and the more it is exercised the more proficient it seems to become.

Lectures are useless: no one remembers anything said after the first twenty minutes

The first time I heard this was from a professor of education who was instructing university staff how to teach, in the days when we were consumed with guilt at having had no specific instruction for one of our prime university duties.  The professor was a likeable enough fellow, but he spoiled his point by developing the theme for 30 minutes longer than his allotted hour. It was then that I began to suspect that educationalists of this genre spoke with forked tongue. A tolerance period of twenty minutes might be suitable for other people’s lectures, but sixty minutes was barely sufficient for theirs.

As we all know, however, there is great variability in the quality of lectures. Some may be boring from the beginning, while others may be spellbinding for hours. But that is beside the point. I do not know a better way to transmit a large amount of information so quickly and so efficiently to large numbers of people. Perhaps that is why it is used so much. People should not forget what is said after the first twenty minutes; they should have made notes. For the passive listener at a lecture, just as for the passive watcher of television, there may be little gained, since mental apathy quickly leads to clouding of consciousness. However, for the active listener, who works hard to understand what the lecturer is saying and interprets this in the form of notes, the lecture is not only instructive but a first-class mental exercise.

At its best, the lecture has the excitement and drama of good theatre. It is very exciting to see and hear a person performing live, allowing us to watch his mind at work and see how he thinks. It is never the same when we hear it later on tape or on television; it is not even the same in simultaneous broadcast in an overflow theatre. There can be something magic in the atmosphere at a lecture and the rapport that occasionally binds a speaker to his audience that must be almost as old as the theatre or man himself.

People learn more from small-group discussions than from lectures

If this is true, I am an exception. I find the diffuse unstructured prattling of a group of people who do not know what they are talking about tedious and irritating. I would prefer someone to do the necessary work to prepare a short talk and then speak without interruption. The audience should then be allowed to ask questions to clarify points of misunderstanding on their part or on the speaker’s. Communicating in this way is not new, it has been the standard form of communication for centuries. Its reasonably disciplined format contrasts greatly with the uncritical verbal outpourings so common in “brainstorming” sessions where groups of ill-informed people share their ignorance.

There is another sort of small-group discussion, where people sit uncomfortably in an embarrassed silence, unresponsive to the verbal prods of a panicky tutor or supervisor. I am not sure which is the less helpful. The system only works well when a group of well-informed and well-prepared people come together to discuss matters of mutual interest.

Another problem with small-group discussions is the inefficient use they make of scarce teaching resources. Unless one is willing to let the students learn only from one another, there are just not enough experienced teachers to go round. With the large size of medical classes and the small number of staff available, there is not enough time for this type of teaching plus the research and supervision activities required of staff.

At one medical school I have heard about, all “teaching” (or as they call it, “learning”) is meant to be conducted through small-group discussions. However, the teachers (“resource people”), finding this on occasion to be a slow, difficult and inefficient way to disseminate information devised another teaching format. In it, all the students gather in one room and a resource person talks to them for about an hour on the topic they all need to learn. They say that this is not a lecture and call it a “fixed resource session”.

Learning should be painless and enjoyable

Not in my experience. Coming to grips with any new subject involves hard grinding work. It is difficult to do when lounging on a sofa, or when sunbathing. In many respects it is like writing; it sounds easy but actually involves tremendous discipline and will power. It requires the ability to sit down at a desk and concentrate while the centre (presumably in the hypothalamus) responsible for the emotional drive to be lazy screams for any diversion, no matter how unpleasant, that will permit postponement of actual work. The mind is particularly fertile in providing such excuses and in my experience these blandishments from the subconscious, or wherever they come from, are very difficult to resist. Perhaps I am unique in having such a highly developed and active laziness centre, but I suspect that others find the discipline of mental work every bit as onerous as I do.

Superficial instruction such as we can get from television or similar passive teaching processes can, I admit, be painless and occasionally enjoyable. But is it of much use in medical education? It usually involves what some medical educationalists would call a “tolerance of ambiguity” on the students’ part and which they believe to be a necessary, if not a good, thing.  I prefer to call it woolly thinking and believe that it is a bad thing. I prefer colleagues to know when they know and also to know when they do not know and to be able to tell the difference between the two.

There is no place for rote learning in medicine

There is a place for rote learning in everything. Words are learnt by rote and words are the substance of thought and communication. The more limited the vocabulary the more limited are the abilities to think and communicate. The same is true in medicine; without the vocabulary of medicine we cannot think about and communicate medicine.   People ask, why learn normal values; one can always look them up in a book?  They might as well say why learn words, one can look them up in a dictionary?   The trouble is that if one has to look up every word, reading becomes slow and thinking almost impossible.  So too with normal values. It is nearly impossible to think sensibly about gas transfer in the lungs unless one first memorises the normal partial pressures of the gases in room air, alveolar air and in the pulmonary blood. Qualitative thinking is not good enough for medical practice; if we really want to understand it, we have to know the quantities.

Practical classes are a waste of time: they just put the students off

In one of my early classes in histology, my teacher, for whom I had an enormous respect and affection, looked at my drawing of the microscopic appearance of a salivary gland and asked why I had drawn lines round each cell. When I told her that they were cell boundaries, she asked me had I actually seen them. I thought I had, but on rechecking the slide I found they were not there; I had invented them. When she then asked me why I had done this, I was rather at a loss but said that it was because of my feeling that all cells must have walls. The lesson she taught me, that I should record what I saw and not what I thought I ought to see, was perhaps one of the most important I have learnt in my life. My sloppy and dishonest thinking in recording invisible cell boundaries was the same as that which permitted people to continue believing Galen’s idea for more than a thousand years that there were pores in the interventricular septum. No one could see them but they felt they must be there; how else could the blood get to the left side of the heart?

I am ceaselessly amazed at the enormous difficulty of observing and making records of phenomena with simplicity and honesty.  Students are particularly bad at this and remain so until they can develop confidence in themselves. They have little difficulty in suppressing in their minds what they really see and substituting what they think they ought to see. Even when we mature, what we see is always coloured by our preconceptions and it requires strong mental discipline and training to minimise the tendency. Practical classes provide an early opportunity for students to acquire this discipline.

Another excellent feature of practical classes is that they let students have discussions with staff in an informal atmosphere and get to know each other’s mental attitudes. This is particularly important nowadays with our large classes in which students tend to feel slightly anonymous and unloved.  Perhaps most importantly, medicine is a practical rather than a theoretical subject. In all its aspects it involves doing things, and doctors who have gained all their knowledge from textbooks are of little use for anything. The range of biological variability is so great that the potted descriptions given by textbooks are much too limited for general application to real life. This is well accepted for clinical work but it is equally true for laboratory work. And what of the statement that practical work only puts them off the subject? What puts people off is knowing too little, not having enough experience, not being proficient.  When people have learnt enough to get on top of a subject and have developed the skills to use it well, they will like it.

Students should be taught principles rather than facts

The truth is that both are needed. Principles are pretty dull unless the facts that they tie together are known. It is not exciting to have the solution without the problem. I discovered this a long time ago when I tried what seemed a brilliant (but not original) idea; give the students a synopsis of my distilled wisdom gathered over the years and tell them everything that was important in terms of fundamental principles in physiology in the first six lectures of the course.  Then they could spend the remainder of the two-year course merely filling in the details. To my amazement the students were not excited at all. They sat there in glazed apathy and only revived when I started to give them the dimensions of the red blood cell in micrometres. They told me later in tutorials that they knew all that general stuff; they had heard all about it in their GCSE ‘A’ level courses. They were tired of superficiality and wanted to get down to the real bones of medicine. I was saddened and chastened by this experience, but I haven’t forgotten it.

Now when I wonder why people are doing a thing their way rather than in the new and obviously better way that I have worked out, I consider the possibility that it may be because my new and obviously better way may not work. It is not an appealing possibility, but it is often true.   Principles are only exciting when they help us fit together the little bits of knowledge and experience that float about in our heads and make the whole into an attractive story. We should know this, especially those of us who have shown photographs to our friends. Why are they so obviously bored with photographs which are so replete with meaning for us?  Perhaps it is because they do not know the context of, or the memories associated with the pictures. No wonder they can scarcely suppress a yawn; one might as well show them a principle.

Students are over-taught: they should have more time to think

I think students should be worked very hard. Their minds will never be so adept again at receiving and storing information and they should become accustomed to a heavy intellectual work-load when they are young. For students the days are long and the eyes and ears should be sensitive to every nuance. If anything has to be cut, the useless frivolities of student life such as watching television, card playing and most sports could go. I would guard carefully the time for working, learning, having conversation and interacting with other students and staff.

The leisure ethic has been pushed too hard. If you want an intelligent decision, you do not go to someone whose mind has been lying fallow for some years, you go to someone who is so busy that he has scarcely the time to see you. I find that new thoughts come to me most frequently after periods of intense sensory input. Physiologically, this is not surprising; our brains are basically reflex machines and our output of thoughts must be related to the input of information. So I am quite unsympathetic to the idea that teaching time should be cut. After all, classes are voluntary and students do not have to attend if they do not want to. The university should set the expected working capacity of students at a high level. They will find that they can work just as easily up to a high level as down to a low one. Students should be encouraged to put as much retrievable information as possible into their memory stores. It will increase their capacity to think and they will never know when they might need it.

There should be more time for elective study

This could be true for the highly motivated and curious student. One of the problems of the medical course is that its range is so great that there may not be much opportunity for study in depth. It is important that some of our students should learn that nothing is easy, that to do anything really well even in a tiny field requires prolonged study, application, and thought. Nothing serves this so well as the elective year in the middle of the medical course. I found this year one of the most valuable and enjoyable of my life and it did more than any other experience to determine the mould of my mind.

What I am uncertain about is whether all students can enjoy and benefit from the experience. We all know of students who when given elective opportunities, elect to have a vacation at public and/or parental expense. These vacations may, especially if taken somewhere like Peru or Detroit, be highly educational in the broad sense, but I doubt if they should be paid for with tax-payers’ money. I would like to see some financial sacrifice on the student’s part as a test of motivation when such vacation electives are taken.

Many students merely wish to qualify in the shortest possible time, with the least possible effort, and to obtain a place on a good vocational training scheme. This is a legitimate position to take; after all medicine needs all sorts. For such students, however, electives may not be a good thing. Bowing to peer pressure, they may not want to be seen to be electing to do work; it may smack too much of the bookworm for their style. The fact that elective work is not so readily examinable may give it a low importance rating for them when they decide their priorities for expending effort.

What all this means is that when debates are taking place on the amount of curricular time to be given to elective study, people should be aware of these two broad categories of students. The thoughts, motivation and aspirations of the members of the curriculum review committee may not necessarily be shared by the entire student body, and opportunities for elective study should be tailored accordingly.

The marks of individual students should not be made public

Our university had a pretty fierce debate on this subject about fifteen years ago when it was more fashionable. It took place in a body called the academic board, that consisted of elected and ex-officio members of the staff and student body and had been set up so that students could play a fuller role in the government of the university. The case for banning the publication of marks (and results) was put by the president of the students’ union. He argued that results and marks were personal matters and should be posted to each individual in a plain sealed envelope. Knowing the President quite well, I could see that this was a case of “special pleading”. He had not passed many examinations since coming to university and therefore found the publication of such matters particularly and personally offensive. As it turned out, when the students discovered the delay in knowing their results (and therefore in starting dates for their summer jobs) that the logistics of such a difficult exercise would cause, the case was lost. The president left us shortly after his year in office and is doing very well, I believe, in shoe manufacturing.

The whole episode illustrated to me what is well known to many others - that many of the students sitting on university committees are not normal students and their views may differ greatly from those of the majority of students they represent. To find out the answer, it is often useful to take a student poll on the matter. Our department once wanted to call a group of students for viva examination; some of them were being considered for honours, others were on the pass/ fail borderline. We thought it would be kinder to list them on the board without category. It seemed humane but it did not work. Many of the people who were up for honours thought they were about to fail and became acutely anxious. Students who were on the pass/fail borderline felt it was unfair of us to withhold that information, which they felt they needed in order to react appropriately. In a poll the class voted overwhelmingly for two separate lists and we rapidly acceded to what in retrospect seems a very realistic approach.

Students want to know how hard they should work and use the feedback from examination results to titrate their work to meet the target they set for themselves. Not only are they concerned about working too little, but many are concerned also that they may be working harder than is actually necessary at the expense of their leisure interests. Why should the students be denied what they want and need?

There should be no such thing as failure

This again is an admirable egalitarian sentiment better suited to theory than to practice.  If we do away with the word “failure”, we need a suitable euphemism to replace it.  “Refer” is popular with many medical schools and some of the Royal Colleges.  In GCSE ‘0’ level examinations, a D grade is not a fail but if you get too many of them the state will not pay your tuition fees for you to work for ‘A’ levels.

Though I cannot prove it, I suspect that I am not alone in needing the stark possibility of failure to inhibit my laziness centre sufficiently to do the work necessary to meet my objectives. Therefore, regardless of standards, it is probably good educationally to have a small fraction of each class fail to stimulate the others. The size of that fraction is a matter for debate, but for the sustenance of individual effort, I know of nothing better than a healthy fear of failure.  

Essay questions are essential to test the candidate’s ability to reason clearly and draw together the strands of a cogent argument

I have to accept the principle underlying this statement. But how does it work out in real life? Like most of my colleagues, I have put seemingly endless hours into reading examination essays and I would not count them among the most joyful in my life. I read about three brilliant essays a year, hundreds of rather mediocre ones, and a few really frightful ones. Students do not have the time or the mental state for composing good prose in examinations. If they spend too much time reasoning out the questions, they do not have enough time to write down the answers. So most answers tend to be the spilled contents of that locker in the mind opened by a trigger word in the question. As examiners we tend to speed-read our way through the piles of scripts scoring more on content than on style. We would not wish to fail a candidate for style if the content were adequate, though good style would be rewarded with bonus marks.

Despite all this, I feel that answering questions in essay form is a very good form of examination in that it dictates to some extent the way students are taught and how they approach the material they attempt to learn.

Multiple-choice questions are educationally unsound since they do not test thinking ability

Judging by the amount of thinking that is necessary to construct a good multiple-choice question, I would be very surprised if some thinking skills were not required to answer it. Certainly, the amount of heated debate that the questions and answers can engender in their testing stage suggests that they are thought-provoking. Anyone who has taken the trouble to learn about multiple-choice question technique could not dismiss them as fit only for testing factual recall. Though it is easy to construct bad questions, it is possible to devise questions which discriminate clearly between good and bad students. A weakness of multiple-choice question papers is that they can only put the candidates in a rank order and decisions on the level of the pass mark tend to be somewhat arbitrary; this does not matter much if they are used in conjunction with other types of test.

Examinations should not be competitive

In a truly egalitarian society one can see the obvious appeal of such a maxim. However, it misses the important point that in real life, society is competitive. At the moment more people want to enter medical school than there are places, therefore we ration places by competitive examination. But why not finish with competition after people enter medical school? After all, if we want them only to reach a certain standard, they need not vie with each other for top places. Sadly, this doesn’t work either. A medical school I know, whose detestation for competition borders on the doctrinaire, has had to rethink its practice. It found that the hospitals to which its graduates had applied for intern posts wished to know if the graduates concerned were excellent, very good, bad, or indifferent, on the grounds that they would prefer the excellent. The school reluctantly introduced grading of achievement, making the examinations competitive, for otherwise their graduates would not have got house jobs.

In my opinion, students do not mind competition as much as many staff think. They take part in competitive sports and would not want every match or race to end in a draw. Students are remarkably aware of the relative intellectual abilities of the other members of their class and, in my experience, are not consumed with envy or jealousy because some turn out to be more able than others. Some of my happiest recollections are of the warmth and pleasure with which final-year classes greeted the announcement of honours in Final MB to one of their number when the results were called. I would like to think that they would be just as magnanimous in later life if one of their peers were to be elected President of the GMC, or knighted, or both.




'Pre-emptive cringers'

The Pre-emptive Cringe

(To see a comment regarding this article go to the 9th February 2014 blog)

What stance should academics take when faced with uncongenial pressures applied by an unsympathetic government?

At a recent congress, some of my Australian colleagues were talking about the strategies being used now by demoralized academics to curry favour with government funding agencies and to limit the damage that might be done to their institutions by government cutbacks. Gone were the halcyon days when confident and fluent university presidents and vice-chancellors instructed timorous governments in precise and certain terms on just where and how universities should be expanded to lead the country into peace and prosperity. Gone also were the days when meek and compliant officials in the government departments of education entertained these proposals with the deference and trust that many academics had become to feel was their right.

With typical Australian word economy, they told me that one of the most popular ploys to curry favour nowadays was the “pre-emptive cringe”; it was the ploy of choice for many of our academic leaders. I had not heard of this but the concept is really quite simple. When some government department promulgates a ‘‘new system’’ for restructuring the education sector or turning conventional wisdom upside down, many academics feel a natural inclination to point out that not all change is progress and that many so-called reforms may do more harm than good and lead to consequences that are difficult to foresee and may indeed be the opposite of those intended.

Pre-emptive cringers stifle this natural and reasonable response. They welcome the diktat and praise it as an imaginative, brave, and inevitable new initiative without which education in the twenty-first century might flounder. They may even point out that many of the features of the new system had already been discussed at the highest levels in their own institutions and, though not thought through with quite the same rigour and clarity as used by the government analysts, had resulted in exactly the same conclusions. Indeed, some of the new ideas were almost ready to implement once the necessary funds were forthcoming. In fact only a shortage of funds had stopped them from launching an almost identical scheme. My colleagues told me that this was a common response nowadays.   Even in Physiology some departmental chairmen had adopted the same tactic when faced with an imposed curricular change or restructuring they believed would damage their subject.

When I suggested that such people had forfeited any right to be called academic or scholarly and should be denounced as the self-serving charlatans they were, I was told that I was being too simplistic. The pre-emptive cringers had only the best interests of their institutions at heart. Though they did not actually believe in the causes they publicly espoused, they honestly felt that to take any other course would not really change the government’s view and could lead to institutional or personal disadvantage, either when the formula for the next distribution of funding was being worked out or when thought was being given to the next round of appointments to government advisory committees.

I still think that the pre-emptive cringers are wrong and that they do the university system a disservice. Academics are the trustees of important bodies of knowledge and habits of honest and rigorous thought which should be guarded and protected with a determination commensurate with their importance to future generations. Academics should only espouse causes they think are fundamentally right. If they do not believe in what they are being asked to do they should say so regardless of the financial and personal consequences of so doing.  They enjoy a very privileged position, relatively free from market forces, able to take the long-term academic view rather than the short-term political or business view and with a mandate to pursue truth no matter where it leads.  If the academics will not speak for truth as they honestly see it, who else will do so?   If they do not cling to high standards, who else will struggle to maintain them? The only valid thinking in a university is honest thinking, and the world is full of examples of institutions that have failed and ceased to contribute because they were driven or bullied into a doctrinaire thinking required to meet political as opposed to scholarly ends.

When a person has to divide his mind with one compartment for truth and the other for lies and half-truths, he ceases to be an effective academic. The main objective of the university is to educate and train the minds of the intelligent young so that they can carry forward and extend the rich heritage of knowledge and innovation bequeathed to us by our predecessors. This heritage was not won easily. It required individuals to speak out for truth and common sense when the fashionable consensus was to speak out for lies and nonsense. Certainly it was not won by the pre-emptive cringers, and those academic leaders who do so should be ashamed of themselves.

From PERSPECTIVES – NEWS IN PHYSIOLOGICAL SCIENCES published by the American Physiological Society, February, 1990. Written when a Visiting Professor in the Department of Physiology at the Chinese University of Hong Kong, Shatin, New Territories, Hong Kong



'Albus Dumbledore'

The Quality of Teaching

(To see a comment regarding this article go to the 9th February 2014 blog)

A paper presented in a symposium on "The Doctor as Teacher" organised by the Association for the Study of Medical Education at The Royal College of Physicians, London, 1987.

There is a widespread belief that students are over-taught and that their intellectual potential is undermined by excessive spoon feeding.  To avoid this it is sometimes advocated that students should not be taught at all but allowed to discover their own ignorance and correct it for themselves by appropriate actions.  However, I suspect there is no substitute for good teaching.  I go along with the experience of Dr Tosteson, Dean of the Harvard Medical School.  He found that people, when asked about what had most influenced their education, usually did not mention a particular course, institution, book, place or idea.  In most cases they mentioned a person, a teacher who had opened their mind to the excitement of intellectual pursuits.

I suspect that such teachers are the most important ingredient in education and the synergism between good teachers and pupils is the very stuff of education.  I should be careful how I sound here.  Some teachers talk about education as teenagers talk about sex; as if they were the first to discover it.  We must be wary of such arrogance.  Like sex, teaching is a very old biological phenomenon.  Passing information from one generation to the next is absolutely fundamental for the survival of a biological species where each individual has a finite life span.  The biological drive to pass on information to one's offspring is as real and pressing as the drive to reproduce.  Yet we know that some teaching is excellent, much is passable and some is awful.  What's the difference between the best and the worst?  I suspect the difference lies in the quality of the teachers involved.  It doesn't seem to depend on the structure of the courses; some highly structured courses can be very boring and turgid while some virtually ad hoc teaching can be very effective.  It doesn't seem to depend much on the intrinsic interest of the subject.  When at school, I found Latin a most exciting subject but physics indescribably dull.  As I know now, of course, it isn't that Latin is more exciting than physics; it is just that my Latin teacher understood and loved his subject so much more than my physics teacher understood and loved his.  In my experience, good teaching doesn't even correlate well with the amount of formal teacher training available or with the number of audio-visual aids put to use.  I have never been turned on by teaching where the medium of instruction was the view-foil and I find most educational TV programmes soporific.  I think one should expect no more from educational training manuals and audio-visual aids in educational relationships than one should expect from sex manuals and sex aids in sexual relationships.  There is a good case for spontaneity and trusting to instinct in both. 

What have the good teachers got that the bad ones have not?  If we knew what is was and how to measure it, how easy life would be.  The good teachers that I remember had some characteristics in common.  Firstly, they loved the subject they taught, understood it well, and had an insatiable curiosity about it in all its aspects.  Sometimes, this love had built up slowly from studying the subject in depth through research under the influence of a superb teacher.  In most cases these people had a very distinguished academic pedigree, were very clever and had an infectious enthusiasm for their subject.  Secondly, they took enormous pleasure in explaining to others what they had learnt and understood.  Those of us who are scientists will know something of the near ecstasy that comes when after months or years of confusion, concepts emerge which make the pieces of a problem suddenly fit together and make sense, and also of the wish that follows to share that knowledge with others.  It is not new; Archimedes must have felt it as his principle of flotation became clear to him in his bath.  He, as you remember, rushed naked through the city shouting "Eureka, I have found it". 

The good teachers that I have known have had something of that enthusiasm to communicate.  Thirdly, they had an affection and respect for their students which bordered almost on love.  Equipping their students to cope with the future was paramount to them.  They would wish for their students what parents would wish for their children.  This affection and respect was reciprocated fully by the students they taught.  Students are very perceptive in recognizing those people who satisfy their thirst for knowledge and usually reward them with warmth and gratitude.  Fourthly, they had an immense capacity for hard work.  Often this was not apparent at the time.  We assumed that the effortless way in which they could communicate ideas clearly was a lucky accident of their mental make-up.  Some of us learnt later that their casual and effortless style was the product of an immense amount of preparation, hard work and rehearsal.  Fifthly, they showed remarkable intellectual humility considering the extent of their skill and knowledge; they never crushed the aspirations of their students but handled their youthful dreams with gentleness. 

I remember once when I was a postgraduate student I worked out what seemed to me a brilliant idea and I took it hot-foot to my chief to whom I explained it at length.  When I had finished he apologised for being so slow and asked me to explain it again.  Making appropriate allowances for his ageing brain I did so more slowly but he still didn't seem to understand.  It was on my third and slowest explanation that I saw the flaws in my own argument and said that perhaps the idea needed a little more work.  He agreed with me kindly and said he would be interested to hear the outcome. 

Sixthly, they rarely seemed to need more than a piece of chalk or a pencil and old envelope to explain their ideas.  Their ideas were never lost in educational technology.  They had the skill to strip their explanations of distractions and pretentious trivia so that the essential message struck home.  Finally, they usually had had a wealth of teaching experience.  I don't remember many good teachers being excellent de novo.  The best were professionals who had learnt their business the hard way, by planning to do it right, getting it a bit wrong, absorbing the lesson, trying to do better the next time and so on for as long as they continued in business. Such people are rare but it's important that students are exposed to them at some time on their way through medical school. 

If there is a fool-proof recipe for selecting such people as teachers, I don't know it.  In making selections I have been wrong almost as often as I have been right.  In my ignorance I tend to be pragmatic rather than doctrinaire but I have some general guidelines:

  1. I would pick as teachers only people who were national or international experts in their subject.  Unless they had such expert knowledge, I fear that they would become dull teachers and no amount of teacher training would help them.
  2.  I would give them full responsibility for whatever part of the course they were asked to teach.  I would encourage them to be innovative in an attempt to make their bit the most exciting part of the entire course.  I would encourage them to use as many audio-visual aids and educational gimmicks as they wished if only to learn that these can never substitute for the educational chemistry that ought to bind student and teacher. 
  3. I would give them a heavy and persistent teaching workload.  The only effective way to learn about teaching in my experience is teaching, so young teachers should have as great a load as is consistent with their main function, the effective pursuit of new knowledge in their own field of study.
  4. I would get rid of them if, in spite of these precautions, they remained ineffective as teachers in the eyes of their students after an adequate probationary period.  Bad teachers damage not only their own course but the students' attitudes to learning.  At that stage I am not sure that sending them to remedial classes would help much.
  5. Finally, I would give them the only bit of general teaching advice that I have found to be valid in all circumstances: Never speak or teach for longer than the allotted time.  People will forgive nearly anything provided it doesn't go on and on.  In that hope I will stop.


  © Copyright James Jackson 2014