Must undergraduate medical education be hospital-based?

Undergraduate medical training is traditionally built up around teaching hospitals. Preclinical teaching may be located separately, and many medical curricula include some preceptorship in general practice. However, the main body of medical teaching is hospital-based. Hospitals provide patients relevant for clinical teaching and students are also trained in the structure of hospital work.

In the last decades, however, teaching hospitals have met increasing difficulties in providing adequate learning conditions. Causes are increased patient turnover, increased workload for the staff, and better awareness of patient safety and patients’ rights. Further, most university hospitals experience an increasing number of students and diminishing resources. In general, modern hospital management is usually not aimed at or ideal for teaching purposes and sufficient premises favourable for clinical teaching are not always available.

These challenges have stimulated development of several new training methods based on simulation, such as skills labs and extensive use of simulated patients. Fiction-based teaching is needed for successful amendment of the increasing problems of hospital-based medical training. The didactic base for simulation is well documented, also in theory. Simulation may be carried as far as blurring the boundaries between fiction and reality and is well accepted by students [1].

Nevertheless, the base in large university hospitals is maintained. The patients carrying the necessary diseases are there, as are the clinical teaching infrastructure and the dedicated teachers, and all these factors are regarded as obligatory preconditions for successful training of coming doctors. Or are they? What if a medical curriculum was general practice based instead of being hospital-based?

General practitioners might be specifically trained for the purpose. Plans for specific challenges may be worked out, progressing year by year from year one to year five or six. The idea of basing a medical curriculum in general practice has several interesting didactic aspects.

One of these aspects is the increased possibility for individualized learning adjusted to the students’ personal learning style. Ideally, a professional curriculum should stimulate each student's capacity for professional development. What will happen if the learning conditions really give each student the necessary stimulus and personal conditions for developing and carrying out her/his own learning strategies? We do not know, as contemporary student cohorts are usually far too large to favour the development of individualized learning. It is my impression, however, that students are well capable of identifying their learning needs and embarking on their personal learning project when exposed to the multitudes of impressions and challenges in a general practice consultation.

Another interesting aspect of basing a medical curriculum in general practice is the possibility of experiential learning when one or a few students are allocated to one general practitioner. Professional development requires experiential learning [2]. Experiential learning in itself also both encourages reflective practice and stimulates the students to learn from experience with the aim of facilitating integration of theory and practice [3].

The Danish philosopher Soren Kierkegaard stated that if you want to help somebody, you must first find him where he is, because not until then may you go further forward with him. If a few students were allocated to each GP, the GP could easily follow her/his students throughout their studies, acting as a personal teacher and a coach for these students. Students could then develop their individual learning plan in collaboration with their GP mentor, and revise it when necessary.

Furthermore, in several countries general practice has in recent years become a full-blown academic profession, well capable of forming the base for a medical curriculum [4], [5].

At this point one may ask, what structures, remedies and other resources would be needed to train a student to become a graduate general physician if the curriculum were general practice based? Every curriculum need premises and staff constituting a pedagogical unit. Activities for the students in this unit may be sketched as PBL groups, skills labs, and different methods of simulation. Experiences with these didactic strategies are abundant. In addition, why not let PBL group tasks be a combination of a written task and a clinical meeting with a simulated patient? The limits in learning from simulation have yet to be discovered.

Any drastically new curriculum must have a research unit coupled to the pedagogical one. Research on medical education is challenging but absolutely necessary, as costs are large and documentation mandatory [6].

The basic curriculum sketched above may be extended. State-of-the-art lessons could be bought through the Net or otherwise organized on the spot depending on local context. The Internet has made access to dedicated teachers unlimited, as several prestigious medical schools provide for sale taped lessons by their expert teachers.

Further, most patients do have a home address where they may be recruited for teaching purposes elsewhere than the teaching hospital. Lessons based on patients with special diseases may be set up with invited experts in the field. Students should also have preceptorships in nearby hospitals, to learn the management and routines of hospital wards.

A medical study based on an individualized curriculum, adjustable over time depending on the students’ needs, will probably be better suited to developing a sufficiently professional student with regard to knowledge, skills, attitudes, and reflective practice than the current ones based on overcrowded hospitals. As I have sketched above, albeit too briefly, a general practice based medical school may not only be feasible, but also probably favourable for aiding enthusiastic youngsters in their transformation into professional and competent physicians.