Personal View: Teaching students—whose job is it anyway?
Authors: Anisur Rahman
Journal: BMJ (2005)

Two new consultants, Dr A and Dr B, have just been recruited to a department in a teaching hospital. The existing consultants know that teaching on their firm is reputed to be poor and badly organised and expect one of the new consultants to take the lead in improving this.

Dr A has been appointed to an NHS consultant post. The clinical director makes it clear to him that his success will be measured in terms of clinical service, audit, reducing waiting lists, and perhaps management activity. Dr A does not feel that these commitments will leave him much time for teaching and feels that organisation of teaching is the responsibility of clinical academics anyway.

Dr B has been appointed to a senior lecturer post. The head of her academic department makes it clear to her that her success and prospects for promotion will be measured in terms of her research output, chiefly grants obtained and papers in journals with a high impact factor. Dr B therefore resolves to spend as much time as possible working on basic science. She has spent most of the last six years in prestigious research fellowship posts with no teaching requirement. She does not feel that she has the time or relevant experience to take a lead in teaching clinical students. She argues that all her NHS consultant colleagues are claiming at least one programmed activity for teaching, so they bear as much responsibility for it as the academics.


It comes down to how important we think teaching is


The example is entirely hypothetical, but the arguments will be familiar to many. Of course, Dr A and Dr B are both correct, and each could argue that time spent teaching would be detrimental to their own chances of succeeding in their posts. Like most clinicians, both would probably agree strongly that it is important to have good teaching in a medical school. They might also agree that obtaining a consultant post in a teaching hospital obliges a doctor to teach. They would disagree about whose job it is to ensure the quality of teaching.

The demand for teaching in medical schools is increasing, the number of students being admitted is increasing, and more is required of each student. For example, medical schools are now required to provide a range of student selected components as well as the core curriculum. New methods of teaching and assessment, such as problem based learning and objective structured clinical examinations (OSCEs), are innovative and popular but can lead to an increase in teaching time.

How are medical schools going to meet this increased demand? Dr A and Dr B might try to delegate teaching to their junior staff. However, the impact of the working time directive and partial shifts will probably make it difficult for specialist registrars to offer regular teaching slots. In any case, this is not a clever strategy in the long term, as each specialist registrar will leave the unit after a year.

A larger proportion of teaching could be moved into primary care. There is much to be said for this, because GPs who teach have usually volunteered to do so and are paid directly for this service. However, the increased demands on GPs' time—such as the 48 hour rule—may restrict their ability to devote time to teaching.

We could transfer more teaching out of the traditional teaching hospitals to district general hospitals. Again, this could be a good idea and would probably give each student the ability to see more patients and gain more experience.

Another option is to create a new cadre of academics, to be appointed on the basis of teaching ability rather than research credentials. These academics could be responsible for the organisation of teaching. However, they would be unlikely to score highly in the research assessment exercise, and currently no mechanism seems to be in place to reward financially either medical schools or individual departments for excellence in teaching.

In the end, it comes down to how important we think teaching is. Is it a vital part of the work of most doctors, which should be assessed such that there are rewards for teaching well and consequences for doing it badly or not at all? Or is teaching a service that is provided pro bono by enthusiasts in addition to their “real measurable work” in the wards, clinics, theatres, and laboratories? Should funds continue to be distributed on the basis of research success alone, or should we modify the system so that funding takes into account contributions to teaching?

Or perhaps the situation is fine as it is. Suppose that after five years neither Dr A nor Dr B has contributed much to teaching in the department, which is still abysmal. However, Dr A has been successful clinically and contributed to audit and management. Dr B has published widely and well. Do you think that their appointments would be considered a success? If it was not their job to teach, whose was it?