Undergraduate medical education and training is a subject of considerable importance in relation to the quality of learning and teaching opportunities for students, and the ability of the learning environments to support the development of clinical skills and knowledge, professional practice and patient-focused high quality care delivery. The Irish context presents a particular challenge due to changes in the organisation and delivery of medical care into two distinct sectors, private or public, which alters the opportunities offered for medical student experience and focuses services in different ways. While the acute care sector (public) is the one in which most medical students train, it is apparent that there are opportunities to be gained from utilising private hospital and medical locations as well, in order to expose medical students to the widest possible and available medical expertise. However, the quality of the experience in such locations may be questionable, and the range of experiences available may be severely limited
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A review of the literature pertaining to the title will demonstrate some of the key issues around this topic, drawing on literature from the UK and internationally, due to the commonalities in medical education structure, form and pedagogy that are found globally, and in particular, referring to the UK model as being the one which dominates still even in the Irish medical education sector.
Due to changes in the healthcare structure in Ireland private, there has been a split in the way that doctors provide acute medical and surgical care services. Within Ireland in the healthcare model which has evolved, there are now public only or private only contracts for consultants, meaning that consultants cannot work across both sectors. Prior to this change, a doctor could work across both sectors, meaning that while they could engage in the public sector work that is the meat and drink of medicine and surgery, most consultants made their money in private hospitals, leaving their NCHD team to do their public work. However, the challenges this change poses for the way in which medical education is delivered in Ireland have not really been picked up on in the literature, and so an exploration of pertinent literature, in the light of the author’s contextual knowledge, is important, to explore this impact and to appreciate the scope and opportunities inherent within the new structure.
There is some evidence that the changes to medical education, whilst global, are very real in the Irish context. The issues affecting medical education include “increasing service demands on clinical teachers, the need for shared teaching among different health-related disciplines, the need to incorporate modern educational principles and technologies, adapting to changing societal views of health and disease and the demand for health professionals to be more accountable.” Issues such as professionalism and widening understanding of diversity are inherent in these issues. What this suggests, among other things, is that in order to make best use of the existing resources, areas still untapped need to be accessed, and at the same time, the way that medical ‘education’ is delivered needs to evolve.
Up until the present day, the private hospitals have not really been involved in med education. However, now they are currently making associations with universities who are eager to tap this resource, in order to make use of the private hospital setting for clinical experiences for medical students (and other healthcare students). It could be posited that these hospital present a hitherto untapped resource, full of opportunities, but also as a point of great scope for development of new ways of thinking about and providing more appropriate forms of education. As a public private system becomes more defined we need to start using the private sector to teach medical students. This is particularly important as there have been, recently, significant increases in the numbers of medical students, with public sector hospitals overwhelmed by medical student numbers, exacerbated by graduate entry into medicine adding to the larger and more diverse pool. This may be affecting the quality of their learning, and also the quality of care provision.
There are, however, challenges, because as an unused resource, and an untested learning environemtn, there are not the internal resources, skills, systems and the like already in existence to support the influx of medical students. Similarly, there are lots of new private hospitals opening that are not used for teaching, and these hospitals are not equipped for teaching. This is something to bear in mind, and there is a need to identify the requirements of a hospital being equipped for medical student teaching and learning. Basic needs would be structural, such as the provision of a student centre, student accessible IT services, student support, changing rooms, training laboratories, and the like.
Some of the major concerns are that private hospitals not equipped and did not make considerations for medical student education at the design phase, meaning that making them primary locations for medical student clinical experience could be very challenging and costly. There is also the issue private patients may not welcome students, particularly as they have paid for their care and so want complete control over it. This may mean students being excluded from key experiences. However, all patients in public sector healthcare have the option to not have students present, so this may not be insurmountable, but it would require rewriting protocols, mission statements, and the like to include an educational component.
Another concern is the fact that private hospitals have not yet got to the same level of provision or range of clinical disciplines as public ones. For example, very few have intensive care departments, full time 24/7 consultant cover, emergency departments or major trauma units. Therefore the casemix of patients is elective, and limited, and students if only placed in private hospitals, will not be exposed to emergency. However, the contrary is also true as public teaching hospitals are now getting less elective patients for routine surgeries such as cholecystectomies and hernias. There is evidence to suggest that the relevance of the training medical students receive is of some importance to the quality of their experience and their future skills. There could, therefore, be an argument for cross-sector placements, on rotation, with students doing different placements in different hospitals. This may have the advantage of exposing students to a wider socio-cultural mix of patients as well as a wider pool of medical expertise, both of which may be of significance in the requirements of medical staff in the current climate. Certainly, there is an emergence of a need to develop more creative approaches to clinical medical education which address the social and societal issues affecting health and illness as well as the medical knowledge itself.
This is evident in the emergence of debate around professionalism and professionalisation/socialisation of medical students into their profession, but also into the wider healthcare workforce. While traditionally, medicine has enjoyed a hegemonic position with near godlike autonomy, things have changed and new ways of viewing the medical profession have emerged. This has included a demand for more transparent, ethical practice, for doctors to view patients as individuals within their personal, social context, and the need for doctors to demonstrate respect for others, teamworking skills, and more self-awareness and increased awareness of social responsibility. It also includes the reflexivity and awareness required to underpin the development of clinical decision making and problem solving skills, in general, and in application to particular disciplines and cases. These notions of professionalism and reducing the divide between physician and patient are deemed important for the profession, as long as professional standards are also maintained. This is where the challenge seems to reside, in providing medical students in Ireland with the scope to develop their professional knowledge and skills, along with the development of themselves, and their professional role, across two radically different healthcare provision domains. Yet the research shows that it is the quality of the clinical or practical experience that medical students have which affects both aspects of their development, their clinical skills and their professionalism. Medical education has moved away from the didactic forms that have characterised it for centuries towards a more interactive, student-centred type of training, although not as far as the other healthcare professions have. Therefore, developing the private sector provision could serve a number of purposes, not just providing a useful place for the runoff of extra students currently flooding the public sector hospitals. It could provide the opportunities for students to be assessed in skills and attributes relevant to each sector, as well as each individual case they are addressing. This would represent a more individualised approach to medical education. There is a high likelihood of a considerable amount of resistance to such a reorientation, however, because the traditional, hierarchical and hegemonic structures of the medical profession will not be easily overcome. What changes there are may not be fully bedded down within the Irish healthcare sector. There is also the challenge of ensuring that there are adequate clinical educators available or even employed within this sector.
However, it would also be important to consider the impact of a large amount of private sector clinical experience on the professional development and socialisation of medical students, because much of this occurs within the institutional setting and is affecting by that setting, by the organisational culture, and by the behaviours of others within that setting. Therefore, if students are modelling themselves primarily on what they are seeing within the private sector, this exposure could be detrimental, in the long run, to their professionalism, their awareness, and the ways that the work with others.
The nature of medical education itself is one which may need to change, to reorient itself to a different model of teaching and learning which is more appropriate to modern day medicine. “Continued efforts are needed to reduce the factual load of the curriculum.” It is apparent that in the current climate, with rapid developments in science and technology applied to medicine, and the increasing speed of these developments, that delivering a didactic curriculum is not practical, and instead, medical schools need to be able to “equip students with the skills and attitudes needed to cope with rapid change and lifelong learning.” This includes students learning how to learn in a self-directed, more autonomous way, which would then help to overcome the differences between the sectors and support students in cross-sector working and identifying the learning and development opportunities specific to each. However, the literature shows that in Ireland (as in many other places), the nature of medical education remains quite didactic and offers only limited opportunities for students to work in alternative ways. Yet the requirement for personal and professional development has already begun to be realised in the UK and Ireland, and as such the groundwork has already been laid.
Similarly, literature shows that medical student learning differs depending on the clinical environment, which may be related to the culture of the environment and the purpose of the medical provision, and if this is the case, then a great deal of research will be needed, along with ongoing evaluation, in order to assess the impact of the use of private sector hospitals within Ireland. The literature demonstrates that new ways of learning can be developed and implemented, based on more social, interactive, collaborative models, such as the development of communities of practice. In this case, such communities would need to span the different sectors effectively, and overcome the differences between them, but these could expand to make better use of and collaborate more effectively with the training of interprofessional colleages. This raises the question of whether there are the skills, capacity and even inclination to develop medical education along such lines, although the ongoing benefits of communities of practice would be exponential.,. The need for medical students to emerge as knowledgeable professionalss with the requisite understanding and skills must not be overlooked.,
It would appear that there is a great untapped potential in the use of private sector hospitals in the Republic of Ireland to supplement medical student education by providing clinical locations for practice-based learning. However, this learning may need to be located in a different paradigm to the traditional medical apprenticeship model that has dominated this sector to date. The private sector hospitals would need to be come part of the partnership teams with universities and public sector hospitals. They would need to develop the facilities and infrastructure to support medical students. Medical students would gain a lot from such placements, but it would appear to be best that these form part of a cross-sector rotation of placements, rather than a private setting constituting their dominant clinical learning setting.
The ways in which medical students are ‘taught’ would also need to change, to become more focused on personal and professional development, self-directed learning, and on all the elements of being professional in relation to current definitions of the word, and the social expectations placed upon healthcare professionals. Research is required into how private sector hospitals can be used, how medical education is changed by this and will change the nature of these locations, and how different approaches to new pedagogies will benefit medical students overall. The impact of these changes on professionalism, and the resistance from the profession, will also need to be considered.
Ultimately, private hospitals can support the current provision, but the nature of the healthcare provision in Ireland would have to be considered also in the light of international models and how it intersects with these. Anything which improves student development and the skills and capabilities of newly qualified doctors must be a positive move, but research is needed to demonstrate that this would be so.
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