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The Edinburgh Declaration (World Federation for Medical Education 1988) outlined 12 principles for improvement of medical education. The Declaration summarized the recommendations of the World Conference on Medical Education in 1988, and was endorsed by the World Health Assembly (1989). The goal is to alter the character of medical education to better meet the health needs of all people.
Each of the clinical specialties makes an essential contribution to the curriculum of all medical schools. The reforms to be considered and implemented call for all the specialties of medicine, therefore, to review their curricula at each medical school. The World Federation for Medical Education has sought to promote the review process by initiating international deliberation in six of the specialties (general practice, neurology, otorhinolaryngology, paediatrics, psychiatry and public health), in association with the corresponding world body of each specialty. The Global Neurology Project undertook to explore reorientation of neurological education in keeping with the reforms being advocated.
A Working Group for Neurology was convened at the Royal College of Physicians of London on 16-18 March 1993, to determine the strategies which neurology as a specialty might employ to support necessary change in medical education. The Working Group included representatives of the World Federation of Neurology Research Group on Medical Education, the World Health Organization, Geneva, and the World Federation for Medical Education.
Of the 12 principles for reform in the Edinburgh Declaration the first eight can be achieved by each medical school itself. The last four principles call for wider collaboration of medical schools with governments, other health professions, authorities, and communities. Each of the principles was reviewed by the Working Group for Neurology, and their recommendations are as follows:
(1) ‘Enlarge the range of settings in which educational programmes are conducted, to include all health resources of the community, not hospitals alone’
The Working Group does not support the view that an organ system, such as the nervous system, is the exclusive teaching domain of any one group of specialists. The contribution of primary care practitioners, physicians, paediatricians, general practitioners (family physicians), and of allied health professionals (e.g. nurses) to the teaching of neurology to medical students in a variety of health care settings should be acknowledged and advocated by neurologists. The Group endorses the need for a range of settings for teaching: the hospital wards, intensive care, rehabilitation units, out-patient clinics, ambulatory care, and sites in the community. The implications for appropriate training of the teachers concerned are emphasized.
(2) ‘Ensure that curriculum content reflects national health priorities and the availability of affordable resources’
A central educational unit at each medical school, which should have authority for curriculum development, should be aware of community needs to ensure that the curriculum reflects local priorities, as well as neurological health needs and expectations. Curricula should include information about the health care system in which the student will work after graduation, and the public health aspects of neurology. Main attention must be given to neurological disorders that are common, preventable, treatable, or occur as emergencies. Although students should be aware of the full range of preventive, therapeutic and rehabilitative strategies, the Working Group emphasizes the importance of constraints imposed on the health system by resource availability and national economic growth, and the imperative of optimum care within such limits.
(3) ‘Ensure continuity of learning throughout life, shifting emphasis from the passive methods so widespread now to more active learning, including self-directed and independent study as well as tutorial methods’
The Working Group for Neurology underscores as a guiding concept the value of independent study. Self-directed learning skills can be more readily acquired by medical students if schools replace excessive lectures and fact-based examinations with tutorials and seminars linked to problem-based learning and competency-based assessment, grounded on clinical skills, sound reasoning, and appropriate attitudes and values.
(4) ‘Build both curriculum and examination systems to ensure the achievement of professional competence and social values, not merely the retention and recall of information’
The field of neurology is concerned with disordered nervous system function and mental life, in which the patient’s illness history and personal values are critical in determining appropriate action. The Working Group for Neurology underscores the value of the method of clinical history-taking and the neurological examination, which determines appropriate investigation and treatment. A parallel consideration is that doctors must be generally educated in cultural traditions. Fact-based examinations should be replaced by the evaluation of comprehensive clinical competence relevant to curricular objectives. The examination and assessment process should also reflect the ethnic and cultural diversity of patients and communities, and be sensitive to issues of gender.
(5) ‘Train teachers as educators, not solely experts in content, and reward educational excellence as fully as excellence in biomedical research or clinical practice’
The Working Group for Neurology strongly endorses that educational ability should be developed in all teachers, and rewarded in the same way as clinical skills and scientific attainment. In teaching medical students, neurologists must also convey this doctor’s role as educator of patients, since some prevalent neurological problems, such as headache, may be amenable to self-care once patients are informed. Neurological education should be supported by staff development through training of teachers as tutors, and organized and administered by a central educational unit.
(6) ‘Complement instruction about the management of patients with increased emphasis on promotion of health and prevention of disease’
The Working Group for Neurology supports the priority of restructuring the curriculum to give emphasis whenever possible to health promotion and prevention of illness, enabling patients to assume greater responsibility for their own well-being and the health of their children. Avoidance and control of risk factors relevant to priority health problems such as stroke, head injury, and spinal trauma can lessen the burden of illness more effectively than medical interventions after the fact. Neurological education should stress the importance of detecting and treating hypertension, of avoiding smoking and excessive consumption of alcohol, and abuse of substances that affect the nervous system. The Working Group supports educational programmes for individuals and families about genetic disorders.
(7) ‘Pursue integration of education in science and education in practice, also using problem-solving in clinical and community settings as a base for learning’
The Working Group endorses the integration of the basic sciences with the clinical disciplines, and the epidemiological and behavioural sciences as essential components of the curriculum. Neurology is a clinical field consisting of multifaceted conditions that extend beyond the boundaries of the specialty when viewed from the patient’s perspective. The Working Group emphasizes the value of teaching neurology to medical students as a branch of general medicine, employing a multidisciplinary staff of clinicians and scientists. The problem-focused neurological examination that all medical students learn to perform should be incorporated in the general physical examination, so that it is viewed as a routine procedure. The Group views as fragmentary a curriculum that assigns specific hours or weeks to different specialties, and advises instead a combined and integrated science and clinical programme with a comprehensive approach to patients and populations.
(8) ‘Employ selection methods for medical students which go beyond intellectual ability and academic achievement, to include evaluation of personal qualities’
The Working Group for Neurology maintains that the primary goal of all medical education is preparation for practice, and that admission criteria be congruent with this aim. Neurologists should play a full part in encouraging their medical schools to select students on the basis of both intellectual and non-cognitive attributes, such as communication skills and personal qualities, especially motivation. Applicants should also come from different socioeconomic and ethnic groups, and should be broadly educated with a wide range of interests.
The final four principles of the Edinburgh Declarationcall for reforms depending on governments and other bodies in addition to medical schools themselves.
(9) ‘Encourage and facilitate cooperation between the Ministries of Health, Ministries of Education, community health services and other relevant bodies in joint policy development, programme planning, implementation and review’
Neurological teaching staff can facilitate this process through a willingness to serve on the relevant committees integrating medical education with health care services, and by participating in educational programmes in a variety of care settings, such as local hospitals and ambulatory clinics. Although neurologists have the tertiary care teaching hospital as the focal point of their professional activities, they should also be willing to support programmes of medical education in conjunction with the delivery of primary care in community services.
(10) ‘Ensure admission policies that match the numbers of students trained with national needs for doctors’
An oversupply or undersupply of doctors, and their geographic and specialty maldistribution, are undesirable. The Working Group affirms as the highest priority of each health system the imperative to meet the health needs of all people. Neurological teaching staff should advocate the constant appraisal of the manpower planning process in their country to correct personnel imbalances.
(11) ‘Increase the opportunity for joint learning, research and service with other health and health-related professions, as part of the training for team-work’
Neurological teaching staff should support multidisciplinary learning with many colleagues, especially nursing, physical and occupational therapy, psychology and social work. Medical students should learn the supportive role of the specialist in those situations where other care givers have major responsibilities, especially in primary care teams and public health.
(12) ‘Clarify responsibility and allocate resources for continuing medical education’
All medical students must acquire self-directed learning skills to stay current throughout professional life with the advances in medical practice. The Working Group for Neurology emphasizes as a primary goal that all doctors must be enabled to maintain their professional competence through continuing medical education in their workplace environments, as well as special educational settings.
The Working Group for Neurology affirms its support of theEdinburgh Declaration as a framework for reform of medical education, recognizing the need for all medical and surgical specialties to undertake a critical appraisal of their educational programmes. Like all departments in a medical school, the clinical specialties reflect the internal structure and values of their institutions. They have now to respond also to the educational implications of their mandate for improving the health of all people in their society.
Dr Anthony Hopkins, London; Dr Edgar J. Kenton III, Philadelphia; Dr Matilde Leonardi, Geneva; Professor TJ Murray, Halifax: Dr Michael Ronthal, Boston; Dr Barbara J Scherokman, Bethesda; Professor BS Singhal, Bombay; Professor Athasit Vejjajiva, Bangkok; Lord Walton of Detchant, Oxford.
Coordinators: Dr Matthew Menken, New Brunswick, New Jersey; Professor HJ Walton, World Federation for Medical Education.
Appendix B reproduced with permission of the copyright holders from Medical Education 1994;28:271–4.
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