Postgrad Med J: first published as 10.1136/pgmj.70.828.728 on 1 October 1994. Downloaded from Postgrad Med J (1994) 70, 728 - 731 © The Fellowship of Postgraduate Medicine, 1994

Scenes from Postgraduate Life The history ofpostgraduate medicine education John Lister

Formerly Linacre Fellow, Royal College ofPhysicians, London

Although formal postgraduate medical education pattern of health care delivery. As Sir David Innes may be a recent phenomenon, many long-establish- Williams said in the 60th anniversary issue of the ed medical societies throughout Britain have con- Postgraduate Medical Journal, this development tributed to the continuing medical education of has been erratic, intermittent, unco-ordinated and established practitioners while the specialist the result of the separate endeavours of many societies have made an immense contribution to the different bodies.3 dissemination ofnew knowledge and many consul- In 1921 the Athlone Committee on postgraduate tants regard these societies as the most valuable medical education4 suggested that a university source ofnew knowledge in their field. The need for medical school devoted solely to postgraduate the medical practitioner to devote himself to a medical education should be established in a lifetime of study was stressed by Osler in a valedic- London hospital and associated with London tory address to students at McGill University in University; that the specialist hospitals should be 1905 when he said: 'The hardest conviction to get linked to the new postgraduate school and that a into the mind of a beginner is that the education central office should be set up to co-ordinate and

upon which he is engaged is not a College Course, develop postgraduate activities in London. copyright. not a Medical Course but a Life Course, for which As a result the British Postgraduate Medical the work of a few years under teachers is but a School was established at Hammersmith Hospital preparation'.' becoming a school of the university in 1934 and Osler later became Chairman of the Postgrad- being officially opened by King George V in 1935. uate Medical Association in this country, an It was not until after the Goodenough Report organization set up in 1911 to develop post- was published in 19445 that the British Post- graduate medical training in the UK, although its graduate Medical Federation was set up in 1945 activities were curtailed by the First World War. At receiving its Charter as a School of London the end of the war the Fellowship of Medicine was University in 1947. The federation comprised 12 established by a group of distinguished doctors in institutes and their specialist hospitals together http://pmj.bmj.com/ London, again with the objective of promoting with the Postgraduate Medical School, which was postgraduate studies, particularly for ex-service granted royal status in 1966 and reverted to being medical officers and the two organizations then an independent school of the University in 1974. combined under the presidency ofOsler, eventually The Goodenough Report was mainly concerned becoming the Fellowship of Postgraduate Medi- cine.2

Over the years the development of postgraduate on October 1, 2021 by guest. Protected medical education has been influenced by a series of Table I Medical Acts reports from influential committees, by legislation (Tables I and II) and in response to the changing 1858 General Council of Medical Education and Registration (GMC since 1951) needs of medical graduates in the light of the 1866 Applicants for registration must have passed remarkable advances in medical science and tech- a qualifying examination 'Sufficiently to nology that have taken place particularly over the guarantee the possession of the knowledge last few decades, and in response to changes in the and skill required for the efficient practice of medicine, surgery and midwifery' 1950 Mandatory preregistration year (introduced 1953) Correspondence: J. Lister, M.A., M.D., F.R.C.P., 1978 GMC responsible for co-ordinating all F.A.C.P., Farm End, 10 Burkes Road, Beaconsfield HP9 stages of medical education. Qualifying IPB, UK. examination no longer described as This paper is based on a talk given at the 75th Anniver- examination in medicine, surgery, obstetrics sary celebrations of the Fellowship of Postgraduate and gynaecology Medicine in June 1993. HISTORY OF POSTGRADUATE MEDICAL EDUCATION 729 Postgrad Med J: first published as 10.1136/pgmj.70.828.728 on 1 October 1994. Downloaded from

Table II Committee reports staffed with well-trained consultants who built up teams of junior staff on the firm pattern of their 1921 Athlone Committee Report teaching hospitals. This enabled them to deliver a 1930 Postgraduate Education Committee high standard of care and provided trainees with (Neville Chamberlain/Arthur Greenwood) 1944 Goodenough Report opportunities for obtaining a wide range ofclinical (Inter-Departmental Committee on Medical experience, but teaching was largely unstructured Schools) and based on the traditional apprenticeship model 1948 NHS introduced of British medicine. In most district hospitals, the 1948 Spens Report facilities for postgraduate study were quite inade- (Remuneration of consultants and specialists) quate. With this staffing pattern of district hos- 1961 Platt Report pitals, the general practitioners found that they (Medical staffing structure in hospital service) were becoming isolated from their hospital col- 1961 Christ Church Conference leagues and they lost any bed 1968 Todd Report gradually privileges (Royal Commission on Medical Education) they had previously enjoyed, and even direct access 1975 Merrison Report to diagnostic facilities was limited. (Regulation of the medical profession) Against this background the Christ Church 1979 NHS vocational training regulations Conference was held in 1961 under the auspices of 1981 Short Report the Nuffield Provincial Hospitals Trust and under (Fourth report from Social Services Committee) the chairmanship of Sir George Pickering, Regius 1986 Hospital medical staffing Professor of Medicine at Oxford.7 This conference (Achieving a balance) had a major catalytic affect on the development of 1987 Recommendations on training of specialists postgraduate medical education and continuing (GMC Education Committee) 1990 NHS reform medical education. A number ofimportant factors 1993 Hospital doctors: training for the future contributed to its success. Firstly, the timing was (Department of Health) right, secondly, the participants were influential and committed, and, thirdly, a number of attain- able objectives were identified. The main objectives were: copyright. 1. To promote an educational atmosphere in regional and district hospitals. with undergraduate education but it was a remark- 2. To encourage all consultants to recognize their ably perceptive report, and made important recom- responsibilities for training their junior staff. mendations about postgraduate training. It sug- 3. To restore educational status to all junior staff gested that universities with medical schools should grades. set up boards of graduate studies and appoint 4. To provide appropriate teaching facilities in postgraduate deans; that all hospitals should be district general hospitals. incorporated in a grand educational design based 5. To establish a central body to co-ordinate the http://pmj.bmj.com/ on the teaching hospitals and that a preregistration interests of colleges and faculties, medical year should be introduced. schools and the NHS. Furthermore, in anticipation ofthe introduction Following the conference, university postgrad- of the NHS, the report stated that: 'A nation uate deans were appointed in those regions, where embarking upon a comprehensive health service one had not already been appointed, and in each cannot afford to do without a comprehensive district a clinical tutor was appointed to stimulate system of postgraduate medical education'. and co-ordinate postgraduate activities. The introduction ofthe National Health Service The immediate objective was to promote an on October 1, 2021 by guest. Protected (NHS) in 1948 was a watershed in the fortunes of educational atmosphere in each district hospital the medical profession. It became the monopoly and it was largely due to the initiative of groups of employer ofmedical manpower and medical grad- enthusiastic consultants in district hospitals that uates became dependent on the service both for the early postgraduate centres were built. Often training and for their career opportunities. The there would be a leading activist in the group who Spens Committee in 19486 envisaged that all posts would emerge as the most obvious choice for between house officer and consultant would pro- clinical tutor. The Nuffield Provincial Hospitals vide appropriate training opportunities, but unfor- Trust and the King's Fund made generous contrib- tunately the educational status of the more junior utions towards building costs. However, no exche- posts was soon eroded as the service demands quer funds were available initially and fund-raising increased and, by 1951, only senior registrar posts was an important activity for the clinical tutors and were recognized as being primarily for training. their colleagues trying to establish centres. One of the major achievements of the NHS was This was often a remarkable collaborative effort. the upgrading of district hospitals, which were Consultants and general practitioners contributed 730 J. LISTER Postgrad Med J: first published as 10.1136/pgmj.70.828.728 on 1 October 1994. Downloaded from generously and such evidence of self-help encour- specialist societies with representatives from the aged donations from industry. In many districts, Health Departments, the Medical Research Coun- educational trusts were set up and local business- cil (MRC), the Association of Medical Research men often became trustees. The cost of the early Charities (AMRC), the General Medical Council centres was modest and often no more than (GMC), postgraduate deans and doctors in train- £10,000-£20,000, as they were planned and built ing. Their main function is to lay down criteria for on the basis of providing the minimum facilities to training in the individual specialties and to approve provide immediate needs. Later centres were more posts and training programmes. Hitherto these ambitious, although the majority of those being committees, except in the specialties of pathology planned in 1968 were estimated to cost between and psychiatry, have granted certificates ofaccred- £20,000 and £40,000. During the years 1962-1972, itation to trainees on the satisfactory completion of 228 medical centres were opened and, by 1978, their training. In future, in order to comply with there were more than 300 centres in England and European Community (EC) directives, certificates Wales.89 of satisfactory completion of training will be The opening ofa postgraduate centre in a district granted by the GMC on the recommendation of hospital brought immediate benefits. The centre the relevant college or joint committee. provided a meeting place where hospital staff, One of the major achievements in the field of senior and junior, could meet on common ground postgraduate medical education has been the intro- with their general practitioner colleagues. Building duction of mandatory vocational training for the centres was the first challenge, but structuring a general practice. There were doubts about the suitable academic programme for hospital trainees wisdom of allowing the specific training require- and providing continuing education for general ments for any speciality to be governed by legisla- practitioners was perhaps a greater challenge for tion, but this has caused no serious problems and clinical tutors. The needs of the two groups are much credit must go to the group of general quite different and the difficulty of planning struc- practitioners who dedicated themselves with enthu- tured training programmes for small groups of siasm to the task ofestablishing general practice as

residents soon became apparent, while general a specialty in its own right, with a well-defined copyright. practitioners tended to complain that programmes training programme comprising 2 years in rotating arranged for them by hospital consultants were hospital posts and I year in an approved training often not relevant to their practice. Thus the report practice. of the Royal Commission (Todd Report) in 196810 The Medical Act of 1978 conferred important noted its concern about the inadequacies or unco- new responsibilities on the GMC. Previously res- ordinated provision of training for junior hospital ponsible for the undergraduate curriculum, the doctors. standard of the qualifying examinations and the To establish a more structured form of post- pre-registration year, this new act required the graduate training, it suggested that, following full GMC to set up an Education Committee 'having registration there should be a period of general the general function of promoting high standards http://pmj.bmj.com/ professional training embracing the Senior House of medical education and co-ordinating all stages Officer (SHO) and registrar grades and lasting of medical education'. This act also required the about 3 years. This should be followed by a period Education Committee to determine the extent of offurther training in a specialist field, which would the knowledge and skill to be required for the be of variable duration according to the specialty granting of United Kingdom medical qualifica- concerned. The Royal Colleges and their faculties tions, but no longer defined the qualifying examin- became responsible for approving posts for general ation as being an examination in medicine, surgery on October 1, 2021 by guest. Protected professional training and the health departments and midwifery, thus finally eliminating the concept agreed that only posts approved for training should of graduating omni-competent doctors and recog- be advertised. This provided the colleges with a nizing the need for postgraduate training. powerful sanction against unsatisfactory posts but In 1987, the Education Committee published much of the training, particularly in SHO posts, recommendations on the training of specialists' remained unstructured with service demands tak- and indicated that the GMC hoped to establish ing precedence over training. relationships with the Colleges and faculties in Higher specialist training in senior registrar and respect of specialist training on lines similar to the more recently in registrar posts become more long-standing relationships it had established with structured and co-ordinated following the estab- the medical schools in respect of undergraduate lishment of joint higher training committees or medical education. In its recommendations the equivalent college committees. Thesejoint commit- Education Committee stressed the need for struc- tees were set up by the Royal Colleges, including tured training with a core curriculum, nominated the Irish colleges, the university associations of educational supervisors for each trainee and pro- professorial heads of departments and the tected teaching time. These are all worthy objec- HISTORY OF POSTGRADUATE MEDICAL EDUCATION 731 Postgrad Med J: first published as 10.1136/pgmj.70.828.728 on 1 October 1994. Downloaded from tives but difficult to achieve within the present clinical tutors for funding educational activities in staffing structure of many hospitals. their district. Since then, postgraduate deans have Apart from the frustrations of long hours of become budget holders for the educational compo- work, the dominance of service requirements over nent of the salaries of trainees, which gives them training needs and the uncertain career prospects, powers to withhold funding from unsatisfactory one of the most confusing issues for trainees must posts. be the multiplicity of agencies and individuals now Apart from the need to provide more structured involved in the training scene. training at all stages of postgraduate medical The colleges retain their traditional role of education, there is a need to co-ordinate the maintaining standards by inspecting posts and by activities of all the agencies and institutions conducting higher examinations to ensure a high involved. It was unfortunate that the Council for standard ofentrant to specialist training. The need Postgraduate Medical Education for England and to pass these examinations had led to much early Wales set up in 1970 was not entirely successful in postgraduate training being examination driven fulfilling this function and eventually foundered, and the colleges are sometimes seen by juniors as although the Councils for Scotland and Ireland remote, threatening institutions. The appointment have continued. The Standing Committee on Post- of college regional advisers and district college graduate Medical Education for England set up in tutors has helped to improve the image of the 1988 is not an entirely satisfactory replacement as colleges but unfortunately the role and even the its remit is restricted to advising the Secretary of identity oftutors is not always clear to trainees and State on specific issues and does not extend to the relationship between college tutors and clinical co-ordinating the activities ofthe many institutions tutors is often confusing. The postgraduate dean is and individuals concerned with postgraduate also often a remote figure and few juniors have medical education. Leadership in this field is essen- much idea of his or her role. tial and there is a clear need for closer collaboration The 1990 reforms of the NHS created great between the colleges, postgraduate deans and the concern about the future status of postgraduate GMC. The recent departmental report on specialist

training, especially in Trust hospitals, but Mr training indicates that the Chief Medical Officer copyright. Kenneth Clarke, the then Secretary of State for will be taking the initiative in arranging meetings Health, stated in a speech on 10 July 1989 that: 'The between postgraduate deans and the colleges.'3 quality of care which the NHS can deliver rests This is an important step and the Royal College of entirely on the high standards and excellence ofthe Physicians is already planning to collaborate more training, education and teaching which is provided. closely with postgraduate deans. We therefore need a framework for postgraduate It is perhaps relevant to recall that it was the education and for the continuing education of our colleges that took the initiative in setting up the doctors, and that includes general practitioners, Central Committee for Postgraduate Medical which will maintain and indeed improve our educa- Education, which preceded the three Councils, and tional standards."12 the time seems opportune for them to take active http://pmj.bmj.com/ This was encouraging and the following year it steps to regain the initiative in this field, perhaps was announced that there would be protected through the Conference of Royal Medical Colleges budgets for postgraduate and continuing medical and their faculties, which could become a most education, which would be held by regional post- influential body, in the co-ordination of many graduate deans who would make allocations to aspects of postgraduate medical education. on October 1, 2021 by guest. Protected References 1. Osler, W. The Student Life. Valedictory address to students at 7. Nuffield Provincial Hospitals Trust Conference on Post- McGill University. April 1905. In: Selected Writings by Sir graduate Medical Education. Br Med J 1962, 1: 466-467. Williini Osler. Oxford University Press, Oxford, 1951. 8. Lister, J. Regional Postgraduate Medical Centres. Br Med J 2. HotTbrand, B.I. The Fellowship of Postgraduate Medicine 1968, 3: 736-738. and the Postgraduate Medical Journal. Postgrad MedJ 1985, 9. Lister, J. The Postgraduate Centre Movement. Update. 61: 1-2. October 1978, pp. 43-46. 3. Innes Williams, D. The evolution of postgraduate medical 10. Royal Commission on Postgraduate Medical Education education. Postgrad Med J 1985, 61: 871 -873. (Todd Report), HMSO, London, 1968. 4. Report of the Postgraduate Medical Committee (Athlone 11. Recommendations on the Training of Specialists. GMC Report). HMSO, London, 1921. Education Committee, London, 1987. 5. Report of the Inter-departmental Committee on Medical 12. Clarke, K. Speech to members of the medical profession, 10 Schools (Goodenough Report). HMSO, London, 1944. July 1989. 6. Report of the Inter-departmental Committee on the 13. Report of the Working Group on Specialist Medical Train- remuneration of consultants and specialists (Spens Report). ing. Hospital Doctors: Training for the Future. Department of HMSO, London, Cmnd. 7420, 1948. Health, London, 1993.