Neel Sharma and Chaoyan Dong: Coalition in medical education

Trudie Roberts and Ronald Harden authored a commentary earlier this year which focused on enhancing existing collaborations to solve the challenges in medical education. We wanted to share our insights.

There is certainly need for improvement as alluded to in Roberts’s and Harden’s article and whilst significant steps have already taken place in this regard, more can be done. Without pushing the boundaries currently in place there is no chance to better what we already know or do. Currently medical schools in the UK have different exiting exams for their students. And whilst they are expected to follow the GMC’s Tomorrow’s Doctors dictum, how can we truly quantify this when disparity exists? The Medical Schools Council Assessment Alliance MSC AA is an example of a coalition, particularly in regard to their unifying situational judgement and prescribing safety assessments. Yet we are still not on the same page as several of the Royal Colleges, where all trainees are expected to sit the same standardized exam depending on the specialty they choose. The GMC is keen to introduce a national licensing exam and we feel that this could certainly aid in ensuring uniform exiting standards, similar to the USMLE in the United States. However are exams by themselves the be all and end all? There is currently some discussion regarding entrustable professional activities (EPAs), which are being sold as a grade up from current competency based tasks. With EPAs candidates are only deemed to be entrusted to perform a particular task without supervision if they have demonstrated that they are able to do it over a repeated and prolonged duration. The AAMC currently ensures exiting students should be deemed capable of performing a set of core EPAs prior to residency helping to ensure patient safety during the transition.

As Roberts and Harden point out, the UK media often refer to the inadequacies of newly starting doctors, yet despite all the negativity, a recent poll suggested trust with regards to the NHS as a whole was still viewed highly. In keeping with preparation for clinical practice, learning by doing is never going to lose favour. Of course it is unethical and practically impossible to achieve this during undergraduate days in its entirety and we wonder whether high fidelity simulation should play more of a role. Pilots are expected to undertake regular simulation based activities and both professions are tasked with the responsibility of peoples’ lives on a daily basis. Yet currently simulation is no way near being regarded as a set standard for either students or training doctors. The UK’s current revalidation exercise could be a way of piloting the merits of this.

We also fully agree with the authors that patients must play more of a role in the training of doctors and as yet this is not quite up to speed. We often read the outcomes of educational based studies which question learners on the perceived benefits of an intervention, be it teaching, learning, or assessment. Yet this is a bias in itself. Study investigators are themselves biased, as are journal peer reviewers and learners may feel uneasy about reporting perceived downsides. By including patients as the target audience of interventions we may get a better idea of what is truly valuable. Communication, or the lack of, is one aspect that is often broadcast as an issue by patients and despite the efforts on offer such as role plays we are still getting it wrong. The Patient Advice Liaison Service (PALS) works well in allowing patients to voice their concerns from a clinical perspective and maybe there could be an option to introduce a more educational based focus here. Do exiting students or trainees actually demonstrate the criteria as laid out by Tomorrow’s Doctors’, if not why not and how can it be improved?
We admire the need for an international coalition as highlighted. Yet like Roberts and Harden, who have researched both in the West and the East, we feel this may be problematic. Cultural settings are not uniform. With regards to the former, one setting may for example prefer the didactic lecture platform whereas another may be more receptive to an interactive form of participation. Furthermore less developed countries without similar investment are automatically disadvantaged from interventions that the West can afford, such as technology based educational strategies.

Coalition in medical education is well worth pushing forward and we welcome readers’ thoughts on this.

Neel Sharma graduated from the University of Manchester and did his internal medicine training at The Royal London Hospital and Guy’s and St Thomas’ NHS Foundation Trust. Currently he is a gastroenterology trainee based in Singapore. 

Chaoyan Dong, PhD is a medical educationalist at the Centre for Medical Education, National University of Singapore.

Competing interests: None declared.