198
Inquest on a Curriculum
ailments and the simpler gynaecological condi-
tions; that he should have a wider knowledge of
public health, of national health, insurance, of
compensation and rehabilitation. They see the
general practitioner, in short, as part of the social
welfare organization of the country and would
have him competent to undertake that duty. Nor
are they oblivious of the groundwork on which
such training must rest. They ask for greater
integration in the curriculum, and for orientation
courses which would bring the various subjects into
proper relationship at the outset. One subject in
which an orientation course would be particularly
valuable is anatomy; a teacher suggests that the
whole body might be dissected rapidly before the
class, by an expert, before students are allowed to
begin on a part. All who remember the bewilder-
ment of their first month in the dissecting-room
will agree with him. Some of the detail might be
cut out and he suggests that anatomy should be
taught on younger subjects, preferably beginning
with the foetus, so that students may see the organs
at various stages of development, not only in the
degeneration or atrophy of old age.
Not unnaturally, the most practical suggestions
for improvement of the curriculum come from
general practitioners themselves. They would like
the student to have free access to the patients in
the chronic wards of infirmaries, to see more minor
infectious illnesses like tonsillitis, and more minor
injuries like sprains. They would like him to have
personal experience of dispensing, not of writing
'rep. mist.' and leaving the rest to the dispenser;
to be confident of giving a safe anaesthetic; to
know some practical psychology and more about
mental disease and defect; and to realize that there
is no mystery about children's diseases or infant
feeding. They think he should know more about
the trifling ills of women—such as vaginal dis-
charge, dysmenorrhoea and menopausal symp-
toms—and that he should have some instruction
about sterlity and contraception. He should be
more adept at recognizing the early stages of di-
sease, especially of cancer, and of rheumatic dis-
orders likely to lead to crippling. Above all they
would have him a competent obstetrician. Some
would like six months post-graduate work in mid-
wifery to be compulsory for the general practition-
er. Others consider that instead of spending a
year on general surgery and month on midwifery,
the periods might well be reversed, or at least more
wisely distributed. Students spend hours in the
theatre watching major surgical and gynaecologi-
cal procedures which, as general practitioners, they
will never perform. They enjoy it, naturally;
most of us like to assist, in the French sense, while
a skilled craftsman does his job, whether it be
painting a picture, building a ship, or opening an
abdomen. But watching major operations is a
waste of time in a crowded curriculum and a
scrutiny of the student's timetable would doubt-
less reveal other extravagances; one doctor re-
minds us of the time spent loitering in the front
hall awaiting dilatory chiefs. Time saved from
these and other pursuits might be spent with a
good firm of general practitioners. Some doctors
think the grounding would be adequate if the
student attended at such a practice once or twice a
week for a month or two; some think he should be
resident with the firm for periods ranging from a
fortnight to six months ; others think this experi-
ence could be post-graduate; but none doubts that
the person to train another in general practice is
the general practitioner. This return to the
apprenticeship system, they feel, is overdue. They
do not suggest that it can in any way replace
formal clinical teaching; only that it should supple-
ment it, occupying time which can be spared from
less essential studies. All are emphatic about the
value of resident appointments and some would
like such post-graduate experience to be compul-
sory for a man about to enter general practice.
The foregoing opinions—whether from teachers,
students or practising doctors—are home and
Empire produce; they are what we can learn from
each other. But the experience of other countries
is also instructive, especially when it forms a com-
ment, spoken or unspoken, on our own practice.
The accounts of medical education in various parts
of the world set out on page 260 will repay study.
We have something to learn, for example, from the
Spanish system of selection, by which the best
opportunities go to the best students; from the
high standard of general education expected of
students in France; from the student discussion
groups of Norway; from the German tradition of
experience in several universities; from the keen-
ness, diligence, and team spirit found in Russian
clinics; and from the American principle that
medicine deals not with the disease alone but with
its effects on the patient, the patient's family and
the community. Russia, travellers tell us, finds
us backward in our treatment of women; Spain
thinks the golden age of English medicine is over,
Germans are politely astonished when they find
an English institution efficiently run, and Ameri-
cans have to stop and think when they are asked
to name the advantages of English medical educa-
tion. It is time to make changes. Remembering
the old maxim for examination candidates—'do
the easy ones first'—let us begin by introducing
experience of general practice into the curriculum,
and a higher standard of obstetric training among
those deciding to become family doctors.